I* 

A TREATISE 

OX THE 

THEORY AND PRACTICE 

OF 

MEDICINE. 



/ BY 

JOH1ST SYER BKISTOWE, M.D. Lond., 

FELLOW AND FORMERLY CENSOR OF THE ROYAL COLLEGE OF PHYSICIANS ; SENIOR PHYSICIAN TO 
AND JOINT "LECTURER ON MEDICINE AT ST. THOMAS'S HOSPITAL J EXAMINKR IN MEDICINE 
TO THE ROYAL COLLEGE OF SCK6EONS : FORMERLY EXAMINER IN MEDICINE TO 
THE UNIVERSITY OF LONDON, AND LECTURER ON GENERAL PATHOLOGY 
AND ON PHYSIOLOGY AT ST. THOMAS'S HOSPITAL. 

SECOND AMERICAN EDITION REVISED BY THE AUTHOR. 

0 . 

WITH NOTES AND ADDITIONS, 

BY 

JAMES H. HUTCHINSON, M.I), 

ONE OF THE ATTENDING PHYSICIANS TO THE PENNSYLVANIA HOSPITAL; PHYSICIAN 
TO THE CHILDREN'S HOSPITAL, PHILADELPHIA. 




PHILADELPHIA: 

II E IT E Y C. LEA. 

1879. 



Entered according to Act of Congress, in the year 1879, by 
HENRY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved.. 



COLLINS, PRINTER. 



EDITOR'S PREFACE. 



In introducing the second American edition of Dr. Bristowe's 
Theory and Practice of Medicine to the profession, I feel that, as 
the author has himself written a preface for it, it is unnecessary for me 
to say more than will suffice to indicate very briefly my own share in 
its preparation for publication. My task has been a light as well as 
a pleasant one, for Dr. Bristowe has so carefully and thoroughly 
revised the work that he has left but few deficiencies to be supplied. 
The American physician, however, sees diseases under phases different 
from those observed in Europe. Certain maladies too prevail more 
extensively here than there, or are modified by the peculiarities of 
our climate. I have, therefore, thought it well to retain most of the 
notes which I made to the first edition and to add new ones wherever 
they seemed to be called for. They are not numerous, and, although 
inserted in the body of the text, are readily distinguishable from it 
by being inclosed in brackets [ ]. It is only right to say that in the 
compilation of the article on Hemophilia I have drawn largely on 
the writings of Drs. Immermann and Wickham Legg. 

I am so conscious of the unimportant part I have taken in the pro- 
duction of this volume that, in spite of the flattering manner in which 
the author speaks of my connection with the work, I believe that I 
may without impropriety cordially recommend it as one of the best 
text-books in the English language. Indeed, it has already taken 
this position ; its merits having been generally recognized by the 
medical press both abroad and in this country. 

JAMES H. HUTCHINSON. 



2019 Walnut St., Philadelphia, 
October 11, 1879. 



PREFACE 

TO THE 

SECOND AMERICAN EDITION. 



The second American edition of my work on medicine, which I here- 
with introduce to my American readers, is substantially identical with 
the recent second English edition. 

It is true that I was requested by the American publisher to make 
any further alterations or additions which might, during the interval, 
have suggested themselves to me as desirable ; but I had taken so 
much pains with the revision of the second English edition, I had so 
carefully corrected errors and inconsistencies of teaching, I had so 
ruthlessly struck out whatever seemed to me questionable or superflu- 
ous, I had added so much new matter, and I had so scrupulously re- 
considered even its literary construction, that while fully admitting 
large scope for improvement in all of these particulars, I felt that the 
time had scarcely yet come at which I could venture' to, or at which 
I could with any real advantage, repeat the editorial process. I have 
contented myself, therefore, with rectifying a few slips of the pen 
which I have discovered, or which have been brought to my notice, in 
the body of the work ; and with the addition of a chapter on insanity, 
which from the first I had contemplated, but had hitherto been pre- 
vented by various circumstances from carrying into effect. I think it 
right to add that in the preparation of this chapter (which I admit is 
mainly a compilation), I felt it my duty, with the objects of refresh- 
ing my knowledge of insanity and of giving life to my descriptions, to 
give regular attendance at Bethlehem Hospital on the practice of my 
friend Dr. Savage, the distinguished Medical Superintendent of that 
Institution. 

The success which my work, written expressly for English students 
of medicine, has achieved in America has far surpassed my expecta- 
tions. I have been especially gratified by the kind and appreciative 
spirit in which it has been received by the American medical press, 
and by its extensive adoption as a text-book in the American medical 
schools; for the unbiased opinion of those who are competent to judge, 
is always valuable, and it is a great privilege and a legitimate source 
of pride, albeit a great responsibility, to be accepted as a teacher. I 



Vi PREFACE TO THE SECOND AMERICAN EDITION. 

earnestly hope that the second edition will maintain and deserve the 
high position which has been accorded to the first. 

I have some reason to believe that my name was little, if at all 
known, to the medical profession in America prior to the publication 
of this work, and I was not surprised therefore, that some of my re- 
viewers mistook me for a young man, and that some regarded me as 
a mere literary physician, and my book as a simple compilation. The 
fact however is, that I have been extensively engaged as a teacher 
of medicine and its collateral sciences for the last thirty years, and 
have been one of the physicians to a large hospital for more than five 
and twenty of them. During the whole of my professional life I have 
been connected with St. Thomas's Hospital, at which institution I have 
been demonstrator of anatomy, pathologist for a period of ten years, 
and lecturer successively on materia medica, physiology, general pa- 
thology and medicine ; further, although I have never been a special- 
ist and have given pretty nearly equal attention to all classes of dis- 
ease that have come under my care as a hospital physician, I have 
had special opportunities of studying dermatology, having formerly 
had the charge of the skin clinique for more than twelve years, and I 
have for ten years past given particular attention to the diseases of 
the nervous system. I may add that I have always striven to be a 
close and conscientious observer, that in my book I have largely epit- 
omized my personal clinical and pathological experience, and that few 
even of the incidental remarks and statements which are scattered 
through its pages have not originated in, or been sanctioned by indepen- 
dent thought or observation. I trust the above remarks will not be 
misunderstood. They are intended not to be self-laudatory, but to be 
my justification to my American readers, for having ventured to write 
a book on medicine, and to explain to them that, whether my work be 
practical or not, it is the work of one who has had long and exten- 
sive practical experience, and has been largely engaged for many 
years in the education of medical students. 

I cannot permit myself to conclude this brief preface without thank- 
ing my friend Dr. Hutchinson for the care and trouble he bestowed 
on the preparation of the first American edition of my work, for the 
kind expressions with which he introduced it to the American profes- 
sion, and for the judicious remarks which he here and there introduced 
into the text; and without expressing my gratification that the second 
edition is also to receive the benefit of his valuable editorial super- 
vision. 

J. S. BRISTOWE. 

II Old Burlington St., London, 

September, 1879. 



PREFACE 

TO 

THE FIRST EDITION. 



In placing this work before those for whom it was especially written, 
namely, the junior members of the profession and students in Medicine, 
I may be permitted to make a few preliminary remarks, partly by way 
of explanation, partly by way of acknowledgment, partly apologetic. 

The first thought, as I suppose, of every one who sits down to write 
a scientific book is bestowed upon the arrangement of his matter. It 
was my first thought. The classification of disease, moreover, is a 
subject to which I have devoted a good deal of attention. But I had 
long formed the opinion that it is impossible, in a work on Medicine, 
intended to be practical, to arrange diseases on strictly scientific prin- 
ciples ; and in this opinion further consideration of the matter only 
confirmed me. Consequently the arrangement which I have adopted 
is, for the most part, artificial, and to be defended only on grounds of 
convenience. Certain affections I have grouped together as 4 Specific 
Febrile Diseases but all others with in many cases more or less dis- 
regard of accuracy, have been classified as Local Diseases. I may 
add that, in respect of the diseases of individual organs, I have, for 
the most part, arranged them, though without expressly indicating 
the fact, in the following order, namely: Inflammations, Morbid 
Growths (including Tubercular and Syphilitic Formations), Parasitic 
Diseases, Degenerations, and Mechanical and Functional Affections. 
I have not hesitated, however, in many instances, to depart from this 
arrangement. 

The selection of subjects to be discussed in a treatise intended to 
occupy a moderate compass is by no means easy. Medicine is inex- 
tricably interwoven with Surgery and with what it is now fashionable 
to term 'gynaecological medicine.' Moreover, several other depart- 
ments of practice, especially perhaps insanity, are now relegated to 
specialists, and have attained such importance as to need special hos- 



Vlll 



PREFACE TO THE FIRST EDITION. 



pitals, and to have a literature of their own. And again, many dis- 
eases, and more particularly local diseases, which doubtless have a 
substantial existence, are either not recognizable by specific symp- 
toms during life, or are of very trivial importance, so that it would 
be a waste of time and space even to enumerate them. I trust that, 
under such circumstances, I shall be pardoned for having treated 
some important subjects superficially; for having omitted many sub- 
jects that it may seem to some persons that I should have included 
in my work ; and for having occasionally introduced topics which 
may appear to be beyond the sphere of Medicine, in the restricted 
sense of that term. 

In discussing each subject, and more especially in discussing each 
disease, my aim has been to give in a readable form as much inform- 
ation as I could include within a limited space. With that object, 
my practice has been in every case to read the subject up carefully; 
to compare the knowledge thus acquired or renewed with the results 
of my own experience, in those cases in which I had any experience ; 
and then, having taken a more or less definite view of the wiiole sub- 
ject, and while my mind was still full of it and of its details, to write 
as clear and as comprehensive an account as I was capable of. Each 
article may therefore be regarded as expressing in a condensed form 
the fulness of my knowledge of its subject at the moment at w T hich it 
was written. This method of procedure will partly explain both the 
ex cathedra tone in which I have, I believe, generally expressed 
myself, the prevailing absence of notes, quotations, and references to 
authorities, and perhaps also many inaccuracies and omissions. 

I have, throughout the work, given particular prominence to the 
pathology and to the clinical phenomena of disease ; and in all cases 
in which the clinical phenomena seem to be the direct consequences 
of definite lesions (especially, therefore, in the case of local diseases) 
my account of the morbid anatomy has been made to precede the 
clinical description. It may possibly, however, seem to be an omis- 
sion that I have only occasionally devoted a special paragraph to the 
differential diagnosis of diseases. It is so far an omission that I have 
been driven to it by the exigencies of space. But, on the whole, I 
do not regret it ; for the distinguishing of one disease from another 
disease should depend, not on the simple recognition of a few leading 
characters, which, however carefully selected, are apt not infrequently 
to fail us, but on a bond fide and thorough acquaintance with the col- 
lective phenomena of diseases. The more a student is taught to rely 
on one or two criteria, the less likely is he to investigate diseases 



PREFACE TO THE FIRST EDITION. 



ix 



intelligently, and the more apt is he to be content with hasty and 
inaccurate diagnoses. 

In respect of the treatment of diseases, again, I may appear to 
have been in many cases less full and less specific than I ought to 
have been. The principles by which I have been guided in this matter 
are easy to explain. In the first place, it seemed to me that works 
upon the Materia Medica are the proper source from which to learn 
the doses in which medicines may be administered, and the best 
modes of combining medicines. And in the second place, in consid- 
ering the details of treatment, as given in most works of medicine, it 
appeared to me that their authors had, for the most part, simply recom- 
mended those doses of drugs, those combinations of drugs, and those 
specific modes of administering them, to which they had accustomed 
themselves. I admit that the subject of my last objection will be 
regarded by many from quite an opposite point of view. Neverthe- 
less, while, on the one hand, I should hesitate to force my own routine 
and trivialities of practice upon students, I should equally hesitate to 
force upon them those of other people. It seems to me best, having 
inculcated general principles, and pointed out the specific virtues of 
certain drugs, to leave the young practitioner generally as much 
unshackled as possible with regard to his choice of particular com- 
binations and modes of administration. He is far more likely to 
make a thoughtful physician, and, as I think, to benefit his patient, if 
he adapts his drugs and his methods to the exigencies of cases as they 
present themselves before him, than if he follows the stereotyped pro- 
cedure of some predecessor. 

From first to last I have carefully avoided quoting illustrative cases. 
This course has been forced upon me by the necessity under which I 
labored of compressing my work within the narrowest possible limits 
of space. But it is a course which I adopted reluctantly, and with 
the full knowledge that I was thereby robbing my pages of much that 
might have been instructive, of much, at any rate, that would have 
rendered them pleasanter reading. Every one who has perused them 
knows how much of the charm, the freshness, the vigor, the impress- 
iveness, and the permanent interest that characterize the classical 
writings of Abercrombie, of Graves, of Watson, of Trousseau, and of 
other masters of our art depend upon the well-told cases with which they 
are so richly interspersed. 

I have already referred to the omission to quote authorities of which 
I have been generally guilty. The excuses which I have to offer in 
reference to this matter are mainly the following : I was anxious to 



X 



PREFACE TO THE FIRST EDITION. 



economize space ; I felt, moreover, that my work was not an encyclo- 
paedia, still less a history of medicine ; and again, many important 
additions which have been made to our knowledge, even daring the 
last few years, have already become classical, and form an integral 
part of the great body of Medical Science. My indebtedness, how- 
ever, direct or indirect, to innumerable writers and workers I most 
fully acknowledge ; and among these I must not fail to include my 
senior colleagues and former teachers of St. Thomas's Hospital, the 
value of whose teaching to myself I cannot exaggerate. But there 
are certain works on which I have drawn very largely, and to the 
authors of which on that account I owe special gratitude : these are, 
in pathology and morbid anatomy, Rokitansky's ' Pathological Anat- 
omy,' Cornil and Ranvier's 'Manual of Pathological Histology,' and 
Virchow's writings, including, above all, his marvellous work on the 
'Pathology of Tumors;' in general medicine, Sir T. Watson's 'Lec- 
tures on the Principles and Practice of Physic,' Reynolds's ' Sys- 
tem of Medicine,' Aitken's ' Science and Practice of Medicine,' 
Niemeyer's 'Elements of Internal Pathology and Therapeutics,' and 
Trousseau's 'Clinical Medicine;' and, in special subjects, Duchenne's 
admirable work on ' Localized Electrization,' and the no less admirable 
Lectures by Charcot on the ' Diseases of the Nervous System.' 

I must apologize for the many omissions, errors, redundancies, and 
other faults with which I am only too conscious that my work abounds. 
Fresh from its completion I feel, perhaps not unnaturally, how much 
better I could do it were I, from the standpoint of my present expe- 
rience, now to rewrite it. But this is perhaps a delusion. At any 
rate, I can only take credit for what I have done, and not for what 
I conceive myself capable of doing. The tree must be judged by its 
fruits. 

In conclusion, I beg leave to record my sincere thanks to my 
friends, Drs. H. Donkin and Greenfield, for the kind and valuable 
assistance I have received from them in the progress of this work 
through the press. They have each read and criticized nearly 
every page ; and I owe it to them that many mistakes have been 
corrected, many omissions supplied, and that the reader has been 
spared the infliction of some grammatical inaccuracies and no little 
careless spelling. 

11 Old Burlington Street : 
August, 1876. 



CONTENTS. 



PART I. 

PAGE 

GENERAL PATHOLOGY .... 33 
I. The Definition of Disease . . . • . . .33 

II. The Etiology of Disease 36 

A. Predisposing Causes op Disease 37 



1. Age. 2. Sex. 3. Personal peculiarities. 4. Occupation, habits, 
etc. 5. Previous disease. 6. Heat and cold, etc. 7. Epidemic con- 
stitution. Change of type of disease. 

B. Exciting Causes of Disease 42 

1. Mechanical. 2. Chemical. 3. Vital — parasites, contagia, mal- 
aria, etc. 

III. Physiological Processes in Health . . . .46 

A. Properties and development of protoplasm. B. Simple tissues — 
1, epithelial; 2, connective; 3, tubular; 4, organs. C. Development, 
growth, and maintenance of the organism. Functions, 1, of circula- 
tory system ; 2, of digestive system ; 3, of excretory system ; 4, of nerv- 
ous system. D. Decay and death essential elements in the processes 



of life. 

IV. Physiological Process in Disease 51 

A. Morbid Growth . . . . ... . . .51 

1. General Observations . . . .. . . . . . . 51 



a. Growth and development of cells, b. Conditions associated with 
overgrowth. c. Migration of leucocytes, d. Tendency of morbid 
growth to spread locally, e. Tendency of morbid growth to become 
generalized. /. Tendency of certain morbid growths to limit their 
distribution to certain tissues or organs, g. Connection of dyscrasia 
with the origin of morbid growths, h. Secondary dyscrasia. i. Mean- 
ing of terms malignant and innocent. 

2. Hypertrophy. Hyperplasia . . . . . . . . .58 

3. Inflammation ............ 59 

General account, a. Extra-vascular processes — in cartilage, in 
mesentery, in cornea, in the vascular tissues, b. Vascular processes, 
c. Exudation. d. Suppuration, e. Destructive processes — ulceration, 
gangrene, f. Organization, granulation, and cicatrization, g. Spread. 
h. Constitutional effects, i. Varieties. 



xii 



CONTENTS. 



PAflE 

4. Tumors . . . . . . • • • . . . . /2 

General account. 

a. Connective tissue Tumors . . . . . . . . . 73 

i. Fibrous tumor, or fibroma, ii. Fatty tumor, or lipoma, iii. Mucous 
tumor, or myxoma, iv. Glue-like tumor, or glioma. 

b. Cartilaginous Tumors, or Chondromata . . 75 

Enchondroses ; enchondromata. 

c. Osseous Tumors, or Osteomata . . . . . . 76 

Ivory; compact; spongy. Exostoses. Enostoses. Odontomata. 

d. Nervous Tumors, or Neuromata . . . . . . . .77 

e. Muscular Tumors, or Myomata . . . . . . . .77 

f. Vascular Tumors, or Angiomata . .78 

Simple; cavernous. 

g. Lymphatic Tumors, or Lymphomata . . .. . . . .78 

i. Lymphangioma, ii. Lymphadenoma (lymphosarcoma)', simple inflam- 
mation ; scrofulous enlargement ; lymphadenoma ; leukaemia or leu- 
cocythsemia. 

h. Tubercle and Granuloma ......... 83 

i. Tubercle : gray or miliary ; caseous or yellow. Connection between 
tubercle and adenoid tissue. Relations between gray and yellow tu- 
bercle. Quasi-malignancy of tubercle. Experimental inoculation. 

ii. Syphilitic gummata. 

i. Sarcomata ... . . . . . . . . .88 

i. Round-cell sarcoma, ii. Spindle-cell sarcoma, iii. Large-cell sar- 
coma, iv. Melanoid sarcoma. Psammoma. 
j. Carcinomata, or Cancers . . . . . . . . .91 

i. Scirrhus or hard cancer, ii. Encephaloid cancer ; erectile or hcematoid, 
pultaceous, lipomatous, melanotic, iii. Colloid cancer . iv. Epithelioma, or 
cancroid, v. Adenoid or tubular cancer : 

B. Atrophy, Degeneration, and Necrosis ...... 95 

1. Atrophy and Degeneration . . . . . . . . .95 

General Remarks, a. Cloudy sivelling. b. Mucous and colloid degener- 
ation, c. Lardaceous degeneration, d. Fatty degeneration, e, Pigmentary 
degeneration, f. Uratic degeneration, g. Calcareous degeneration. 

2. Necrosis, or Gangrene ......... 101 

C. Mechanical and Functional Derangements 103 

1. Mechanical Derangements ......... 104 

a. Displacement of parts, b. Compression, contraction, and im- 
paction, c. Dilatation : Cysts, i. Cysts by dilatation of natural 
cavities ; ii. cysts by distension of ducts or retention ; iii. cysts by 
extravasation ; iv. cysts by softening of tissues, d. Rupture and 
extravasation. 

2. Functional Derangements . . 107 

a. Congestion ............ 108 

i. Active, ii. Passive. 



CONTENTS. 



xiii 



PAGE 

6. Dropsy . . . . . . ... . . . 109 

i. General, ii. Local. 

c. Fever ............. 112 

i. Normal Temperature. Conditions which determine and regulate 
heat of body. ii. Febrile temperature. Hyperpyrexia. Symptoms 
attending febrile temperature. Condition of skin ; of circulation ; of 
respiration ; of digestive organs ; of urine ; of nervous system. Cause 
of death in fever. Causes of the febrile temperature. The Thermome- 
ter. Hectic Fever. 

d. The Typhoid Condition 120 

Symptoms. Causes. 

e. Collapse. Syncope . . . . . . . . . . 122 

Symptoms of collapse. Symptoms of syncope. Depression of tem- 
perature. Feebleness of circulation. Condition of nervous functions. 

/. Death 7 124 

i. From failure of nutrition, ii. From failure of the circulation. 

iii. From failure of the elimination of effete and poisonous matters. 

iv. From failure of the nervous system to perform its proper functions. 

The Treatment of Disease 128 

A. Hygienic Treatment .......... 128 

B. Prophylactic Treatment ......... 129 

1. Prophylaxis in relation to the tendency, inherited or acquired, 
to disease. 2. Prophylaxis in relation to parasitic, endemic, and in- 
fectious disease. 3. Prophylaxis in relation to the complications or 
sequelae of disease. 

C. Remedial and Therapeutical Treatment . . . . . . .130 

1. To render the patient's condition as comfortable as circum- 
stances permit. 2. The maintenance of the patient's strength. 3. 
The maintenance or improvement of the nutritive functions. 4. The 
elimination of effete matters. 5. The treatment of symptoms. 6. The 
obviation of the tendency to death. 



PART II. 

SPECIAL PATHOLOGY .... 137 
Chap. I—SPECIFIC FEBRILE DISEASES . . 137 

I. Introductory Remarks in reference mainly 'to the 

Infectious Fevers 137 

A. Specific Origin and Spread of Epidemic and Endemic Diseases . . 137 
1. They originate in specific causes. 2. They prevail endemically 
or epidemically. 3. They are in large proportion infectious or con- 
tagious. 4. Behavior of contagia within the organism. 5. Behavior 
of contagia external to the body. 6. Nature of contagia. 7. Septi- 
caemia. 



xiv 



CONTENTS. 



PAGE 

B. General Rules to be observed in the Management of Epidemic and Conta- 
gious Diseases ........... 144 

II. Influenza (Epidemic Catarrh) 146 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

III. Hooping-Cough (Pertussis) 149 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

IV. Mumps (Parotitis) . . 153 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

V. Measles (Rubeola. Morbilli) 155 

Definition. Causation. Symptoms and Progress. Morbid anatomy. 
Treatment. 

VI. Epidemic Roseola (Rotheln. Rubeola) .... 158 
Definition. Causation. Symptoms and Progress. Treatment. 

VII. Scarlet Fever (Scarlatina. Febris Rubra) . . .160 
Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

VIII. Smallpox ( Variola) 167 

Definition. Causation and history. Symptoms and Progress. Va- 
rieties. Morbid anatomy. Treatment. 

IX. Cow-Pox ( Vaccinia) Vaccination . . . . .175 
Definition. Causation and relations with smallpox. Symptoms 
and progress in cattle. Symptoms and progress in man. Protective 
influence of vaccination against smallpox. Dangers of vaccination. 
Permanence of vaccination. 

X. Chicken-Pox ( Varicella) . . . ... . . 180 

Definition. Causation. Symptoms and progress. Treatment. 

XI. Typhus 182 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

XII. Plague (Pestilentia) 188 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anato*my. Treatment. 

XIII. Relapsing Fever (Famine Fever) 190 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

XIV. Dengue (Dandy Fever). 193 

Definition. Causation and history. Symptoms and progress. Treat- 
ment. 



CONTENTS. XV 

PAGE 

XV. Yellow Fever 195 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

XVI. Cerebro-Spinal Fever (Epidemic Gerebro- Spinal Me- 
ningitis) . . . . . 198 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

XVII. Diphtheria {Membranous Croup) 200 

Definition. Causation and history. Symptoms and progress. Varie- 
ties. Paralysis. Morbid anatomy and Pathology. Treatment. 

XVIII. Enteric Fever {Typhoid Fever. Abdominal Typhus) . 210 
Definition. Causation and history. Symptoms and progress. Va- 
rieties. Complications and sequelae. Diagnosis. Morbid anatomy. 
Treatment. 

XIX. Epidemic Cholera (Asiatic or Malignant Cholera) . 222 
Definition. Causation and history. Investigations during English 
epidemics. Experimental production of cholera. Symptoms and 
progress. Collapse. Reaction. Relations between cholera and sum- 
mer diarrhoea. Morbid anatomy and pathology. Treatment. 

XX. Hydrophobia (Babies) . . . . . . . . 233 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

XXL Glanders. Farcy (Equinia) 236 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

XXII. Syphilis . . . . . . . . . . .238 

Definition. Causation and history. Symptoms and progress. 1. 
Primary symptoms. 2. Secondary symptoms. 3. Tertiary symptoms. 4. In- 
herited syphilis. Morbid anatomy and pathology. Treatment. 

XXIII. Pyjemia (Septicemia) 250 

Definition. Causation. Morbid anatomy and pathology. Symptoms 

and progress. Treatment. 

XXIV. Leprosy (Elephantiasis Grcecorum) 257 

Definition. Causation and history. Symptoms and progress. Va- 
rieties : tubercular and anaesthetic. Morbid anatomy and pathology. 
Treatment. 

XXV. Ague (Intermittent and Remittent Fever) . . . .263 
Definition. Causation and history. Symptoms and progress. A. 



Intermittent fever. Varieties. B. Remittent fever. C. Pernicious or 
congestive fever. Other varieties. Morbid anatomy and pathology. 
Treatment. 



XVI 



CONTENTS. 



PAGE 

Chap. II. — DISEASES OF THE SKIN . . 274 

I. Introductory Remarks 274 

A. Classification and Definition of Terms ....... 274 

1. Macula. 2. Exanthema, or rash. 3. Papula, or pimple. 4. Tuber- 
cles: wheal. 5. Vesicles. 6. Bulla or blebs. 7. Pustules. 8. Furfura, 
or scurf. 9. Squamai, or scales. 10. Scab, or crust. 

B. Tendency of spots and Patches of Shin Disease to assume a Circular Form 27S 

II. Erysipelas 278 

Definition. Causation. Morbid anatomy. Symptoms and pro- 
gress. Treatment. 

III. Carbuncle {Anthrax). Boil (Furunculus) . . . 282 
Definition. Causation. Morbid anatomy. Symptoms. Treatment. 

IV. Erythema. Roseola. Urticaria. Pityriasis . 284 

Causation and description. A. Erythema simplex: pityriasis simplex. 
B. Erythema midtiforme; varieties. C. Erythema nodosum. D. Erythe- 
ma fugax. E. Roseola. F. Urticaria or Nettle-rash : varieties. Treat- 



ment. 

Y. Psoriasis (Lepra). Pityriasis Rubra .... 289 

Causation and description. A. Psoriasis. Varieties. B. Pityriasis 
Rubra. Treatment. 

VI. Ichthyosis 291 

Description. A. Ichthyosis simplex, or Xeroderma. B. Ichthyosis cornea. 
Treatment. 

VII. Eczema (Lichen. Strophulus) 293 

Causation and description. Varieties. Treatment. 

VIII. Impetigo (Ecthyma) 296 

Causation and description. Varieties. Treatment. 

IX. Sudamina. Miliaria > . . 297 

Description. 

X. Herpes. Pemphigus 298 

Causation and description. A. Herpes. Varieties : 1. Zona, or 
Herpes zoster; 2. H. simplex; 3. H. iris; 4. H. circinatus. B. Pem- 
phigus. Varieties. Treatment. 

XI. Rupia 302 

Causation and description. Varieties. Treatment. 

XII. Seborrhea. Acne 303 

Causation and description. A. Seborrhcea. B. Acne. C. Acne 
Rosacea. Treatment. 

XIII. Lupus (Noli me tangere) ' . 306 



Causation and description. Varieties: A. L. erythematosus ; B. L. 
exedens and non-exedens ; C. Pustular lupus. Treatment. 



CONTENTS. 



xvii 



PAGtE 

XIV. Keloid (Kelts) 308 

Causation and description. Treatment. 

XV. Xanthoma ( Vitiligoidea. Xanthelasma) . . .309 
Causation and description. Treatment. 

XVI. Lichen Ruber . . 310 

Description. Treatment. 

XVII. Scleroderma (Scleriasi s. Addison' 's Keloid. Morphcea) 311 
Causation and description. Varieties. Treatment. 

XVIII. Elephantiasis (Elephas. Pachydermia. Barbadoes 

Leg.^ E. Arabum) 313 

Causation and description. A. Elephantiasis. B. Elephantiasis 
Lymphangiectodes. Treatment. 

XIX. MOLLUSCUM CONTAGIOSUM ...... 315 

Causation and description. Treatment. 

XX. Phthiriasis (Lousiness) 316 

Causation and description. A. Pediculus capitis; B. P. vestimenti; 
C. P. pubis. Treatment. 

XXI. Scabies (Itch) . . . . . . . . .317 

Causation and description. Acarus scabiei. Treatment. 

XXII. Other Skin- Affections caused by Animalcules . 320 
Causation and description. Leptus autumnalis. Pulex penetrans. 
Bulama boil. Acarus folliculorum. 

XXIII. Tinea Tonsurans (Porrigo scutulata. Ringworm) . 321 
Causation and description. Tricophyton tonsurans. Treatment. 

XXIV. Tinea Favosa (Favus. Porrigo Favosa and Lupinosa) 323 
Causation and description. Achorion Schbnleinii. Treatment. 

XXV. Tinea Versicolor (Pityriasis Versicolor, Chloasma) 325 
Causation and description. Microsporon furfur. Treatment. 

XXVI. Alopecia Areata (A. Circumscripta. Porrigo or 

Tinea Decalvans) . . 325 

Causation and description. Treatment. 

XXVII. Prurigo 327 

Description. Treatment. 

XXVIII. Concluding Remarks . . . . . . . 328 

Chap. Ill — DISEASES OF THE RESPIRATORY ORGANS 329 

I. Introductory Remarks 329 

A. Anatomical Relations ........ 329 

1. Organs of respiration. 2. Regions of chest. 
B 



XV111 



CONTENTS. 



PAGE 

B. Pathology of Voice, Respiration, Cough, and Expectoration . . 330 
1. Voice: feebleness, absence, pitch, quality. 2. Respiration: fre- 
quency, dyspnoea. 3. Cough: varieties. 4. Expectoration: varieties. 

C. Investigation by Sight and Touch ...... 335 

1. Larynx and trachea. Laryngoscope. 2. Chest : form, move- 
ments, fremitus. Spirometer. 

J). Investigation by Percussion and Auscidtation .... 339 
1. Percussion, a. Normal percussion phenomena : i. Resonance ; 
ii. Dulness. b. Abnormal percussion phenomena: i. Dulness; ii. 
Resonance ; iii. Resistance. 2. Auscultation. The stethoscop>e. a. 
Normal auscultatory phenomena : i. Auscultation of the breath ; ii. 
Auscultation of the voice, b. Abnormal auscultatory phenomena : 
i. Tubular or bronchial breathing ; ii. Amphoric, cavernous, or me- 
tallic breathing ; iii. Bronchophony, pectoriloquy, and asgophony ; 
iv. Crepitation, rales ; v. Rhonchus ; vi. Splashing ; vii. Amphoric 
bubble; viii. Friction sounds. 

E. Detection of Cavities, Consolidated Lung, and Pleural Effusion . 354 

II. Laryngitis and Tracheitis 355 

Causation. Morbid anatomy. Symptoms and progress. 1. Acute 
laryngitis; 2. Chronic laryngitis ; aphonia clericorum ; tuber cidar and syphil- 
itic laryngitis. 3. Tracheitis. Treatment. 

III. Bronchitis . 361 

Causation. Morbid anatomy. Symptoms and progress : 1. Acute 

bronchitis; 2. Chronic bronchitis. Treatment. 

IV. Pneumonia . . 3 QS 

Causation. Morbid anatomy : A. lobar pneumonia ; engorgement, 

red and gray hepatization ; B. lobular pneumonia. Symptoms and 
progress. Treatment. 

V. Pleurisy (Pleuritis) 376 

Causation. Morbid anatomy : effusion; suppuration; consequences. 
Symptoms and progress. Treatment. 

VI. Cirrhosis {Chronic Pneumonia. Fibroid Phthisis) . 385 
Definition. Causation. Morbid anatomy. Symptoms. Treatment. 

VII. Tubercle {Laryngeal and Pulmonary Phthisis. Tuber- 
cular Pleurisy) 389 

Causation. Morbid anatomy : 1. Laryngeal tubercle ; 2. Pulmo- 
nary tubercle ; 3. Pleural tubercle. Symptoms and progress : 
chronic ; acute. Treatment. 

VIII. Syphilis . . . . .402 

Morbid anatomy : 1. Larynx, trachea, and bronchial tubes ; 2. 
Lungs. Symptoms and progress. Treatment. 

IX. Tumors 404 

A. Tumors of Larynx ......... 404 

Morbid anatomy : 1, Non-malignant tumors ; 2. Malignant tumors. 
Symptoms and progress. Treatment. 



CONTENTS. XIX 

PAGE 

B. Tumors of Lungs and Pleura, . ... • . . . 405 

Morbid anatomy : Non-malignant tumors ; Malignant tumors. 
Symptoms and progress. Treatment. 

X. Parasites. Hydatids . 408 

Morbid anatomy. Hydatids. Symptoms and progress. Treatment. 

XI. Bronchiectasis {Dilatation of Bronchial Tubes) . .410 



Causation and morbid anatomy. Varieties. Symptoms and pro- 
gress. Treatment. 

XII. Emphysema . 412 

Causation ^and morbid anatomy: A. Interlobular; B. vesicular. 
Varieties of vesicular. Symptoms and progress. Treatment. 



XIII. Congestion 417 

Causation and morbid anatomy. 1. Congestion of larynx, trachea, 

and bronchial tubes. 2. Congestion of lungs. Symptoms. Treat- 
ment. 

XIV. Dropsy. Hydrothorax 418 

Causation and morbid anatomy. 1. (Edema of larynx. 2. (Edema 

of lungs. 3. Pleural dropsy, or Hydrothorax. Symptoms. Treatment. 

XV. Pulmonary Collapse. Atelectasis . . . .419 



Causation and morbid anatomy. Varieties. Symptoms and pro- 
gress. Treatment. 

XVI. Hemorrhage. Pulmonary Apoplexy. Haemoptysis 421 
Causation and morbid anatomy. Varieties. Symptoms and pro- 



gress. Treatment. 

XVII. Pneumothorax 424 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

XVIII. Paralytic Affections of the Larynx .... 425 



1. a. Bilateral paralysis of the superior laryngeals : b. Unilateral 
paralysis. 2. a. Bilateral paralysis of the recurrent laryngeals : 6. 
Unilateral paralysis. 3. a. Bilateral paralysis of pneumogastric 
nerves : b. Unilateral paralysis. 4. a. Bilateral paralysis of posterior 
crico-arytenoidei : b. Unilateral paralysis. 5. Paralysis of addur-tors. 
6. Paralysis of arytenoideus. 7. Paralysis of thyro-arytenoidei. 
Treatment. 

XIX. Spasm of the Larynx and Trachea .... 427 
1. Larynx. 2. Trachea. Treatment. 

XX. Asthma (Spasm of the Bronchial Tubes) .... 428 
Definition. Causation. Symptoms and progress. Pathologv. 
Treatment. 

XXI. Hay-Asthma (Hay-Fever) 431 

Definition. Causation. Symptoms and progress. Treatment. 

[Autumnal Catarrh ... 432 

Causation and description. Treatment.] 



XX 



CONTENTS. 



PAGE 

Chap. IV — DISEASES OF THE VASCULAR ORGANS 434 



Section I — Diseases of the Heart . . . 434 

I. Introductory Remarks . . . ... . . . 434 

A. Anatomy and Anatomical Relations of the Heart . . . . 434 
1. Dimensions of heart. 2. Relation of heart to pericardium. 3. 

Relations of heart to chest-walls and surrounding organs. 

B. Physiology of the Heart . . . . . . . ' . 436 

1. Action of heart. 2. Sounds of heart. 3. Pulse: varieties. 

C. Pathology of the Heart 441 

1. Mechanical and Structural Derangements ...... 441 



a. Conditions external to heart, b. Conditions involving the mus- 
cular walls, c. Conditions involving the valves ; obstructive aortic 
valve disease ; regurgitant ditto ; obstructive mitral disease ; regurgi- 



tant ditto, d. Conditions involving the contents. 

2. Functional Derangements ... . . . . 444 

a. Motor derangements. 6. Abnormal sensations. 

3. Effects of Cardiac Derangements on the Walls and Cavities of the Heart . 445 

4. Effects of Cardiac Derangements on the General Organisms . . . 447 

5. General Diagnosis of Cardiac Derangements . . . . ' . 44S 



a. Alterations in form of precordial region, b. Alterations in area 
of cardiac dulness. c. Increased resistance, d. Pulsation and thrill. 
e. Abnormal sounds ; pericardial and endocardial murmurs. /. Ve- 
nous murmurs. 

6. Special Diagnosis of Cardiac Derangements 451 

a. Pericardial effusion, b. Pericardial adhesion, c. Hypertrophy 
of the heart, d. Feebleness of the heart, e. Aortic valve disease. 
/. Pulmonic valve disease, g. Mitral valve disease, h. Tricuspid 



valve disease, i. Haemic murmurs. 

7. Prognosis of Cardiac Derangements . . . . . . .455 

8. Treatment of Cardiac Derangements . . . . . . .457 

II. Pericarditis, Myocarditis and Endocarditis . . . 459 

A. Pericarditis .... . . . . . . . .459 

Causation. Morbid anatomy. Symptoms and progress. 

B. Myocarditis 463 

Causation and morbid anatomy. Symptoms and progress. 

C. Endocarditis . . ... . . • . . ... 464 

Causation. Morbid anatomy. Symptoms and progress. 

D. Treatment of Inflammation of the Heart and Pericardium . . .466 

III. Morbid Growths and Parasites 468 



A. Fatty growth. B. Tubercle. C. Syphilis. D. Malignant Disease. 
E. Parasites. F. Treatment. 



CONTENTS. xxi 

PAGE 

IV. Degenerations 470 

A. Degeneration of the Muscular Walls ....... 470 

Causation and morbid anatomy. 1. Fatty degeneration. 2. Granular 
degeneration. 3. Fibroid degeneration. Symptoms. 

B. Degenerations of the Valves and Endocardium ..... 472 

Causation and morbid anatomy. Symptoms. 

C. Degenerations of the Coronary Arteries ....... 473 

D. Treatment . . . . . . ... • . . . . 473 

V. Aneurisms^ of the Heart . . . . ' . . . 473 
Causation. Morbid anatomy. Symptoms. 

VI. Rupture of the Heart. Effusion of Blood into 

Pericardium 475 

Causation. Morbid anatomy. Symptoms and progress. Other 
ruptures of the heart. 

VII. Hydro-Pericardium 476 

VIII. Syncope , . . ...... . .477 

Causation. Treatment. 

IX. Palpitation. Graves's Disease {Exophthalmic Goitre) 477 
A. Palpitation. B. Graves's disease. Definition. Causation. Mor- 
bid anatomy, symptoms and progress. Treatment. 

X. Cardiac Neuralgia. Angina Pectoris .... 480 
Causation. Pathology. Symptoms and progress. Treatment. 

XI. Cyanosis and Malformations 482 

A. Cyanosis . . . . . . . . . . . 482 

Causation. Symptoms and progress. Pathology. 

B. Malformations 483 

Causation and morbid anatomy. Symptoms and progress. 

fc.*-C. Treatment . . . . . . 485 

Section II — Diseases of the Artertes . . 485 

I. Arteritis . . . ..... . . . 485 

A. Periarteritis. Causation and morbid anatomy. Symptoms. 

B. Endoarteritis. Causation and morbid anatomy. Symptoms. 

II. Degeneration of Arteries . 487 

Causation and morbid anatomy. Symptoms. 

III. Aneurism {Dilatation of Arteries') 488 

Definition. Causation. Morbid anatomy. Effects of aneurisms on 
neighboring parts ; results. Symptoms and progress. Treatment. 
A. Thoracic Aneurisms . . . . . . . . 493 

Morbid anatomy and symptoms. 1. Impediment to arterial circula- 
tion. 2. Impediment to venous circulation. 3. Pressure on nerves. 



xxii 



CONTENTS. 



PAGE 

4. Pressure on trachea and bronchial tubes. 5. Pressure on oeso- 



phagus. Treatment. 

B. Abdominal Aneurisms . 497 

Morbid anatomy and symptoms. Treatment. 

Section III. — Diseases of the Veins . . . 498 

I. Phlebitis 498 

Causation and morbid anatomy. Symptoms. 

II. • Varix {Dilatation of the Veins) 499 

Causation. Morbid anatomy. 

Section IV Arterial and Venous Obstructions . 500 

Thrombosis and Embolism . 500 

Definition. 

A. Thrombosis . 500 

Causation. Morbid anatomy. 1. In heart. 2. In veins. 3. In 

arteries. 

B. Embolism . . . , .502 

Causation and morbid anatomy. 

C. Consequences and Symptoms of Thrombosis and Embolism . . . 504 



1. Phlegmasia alba dolens. Treatment. 2. Cardiac thrombosis. 3. Em- 
bolism and thrombosis of the pulmonary artery. 4. Embolism and thrombosis 
of the larger systemic arteries. Treatment. 5. Multiple embolism of the 
smaller systemic arteries. Treatment. 

Section V Diseases of the Ductless Glands, Blood, &c. 508 



I. Diseases of the Thyroid Body ...... 508 

A. Goitre (Bronchocele) ... . . • . . . . 508 
Causation. Morbid anatomy. Symptoms and progress. Treatment. 

B. Cretinism . . . 512 

Treatment. 

II. Myxedema .514 

Definition and history. Causation. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

III. Diseases of the Supra-renal Capsules . . . .515 

A. Addison's Disease {Melasma Addisonii) . . . • . . . 515 
Definition. Causation. Morbid anatomy and pathology. Symp- 
toms and progress. Treatment. 

B. Tumors of the Supra-renal Capsules . . . . . . .519 

IV. Diseases of the Spleen 519 

A. Congestion ...... ..... 519 



Causation. Morbid anatomy. Symptoms and progress. Treatment. 



CONTENTS. 



xxiii 



PAGE 



B. Hypertrophy ........... 520 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

C. Inflammation ........... 521 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

D. Tubercle 522 

E. Tumors 522 

F. Cysts and Hydatids * . . .523 

G. Atrophy . . . . . . . ... . . .523 

H. Lardaceous Degeneration ......... 523 

Morbid anatomy. Symptoms. Treatment. 

V. Diseases of the Lymphatics 524 

A. Inflammation ........... 524 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

B. Tubercle. Scrofula . . . . . " ' . . • 525 
Morbid anatomy. Symptoms and progress. Treatment. 

C. Morbid Growths . 526 

Morbid anatomy. Symptoms and progress. Treatment. 

D. Mediastinal Tumors ......... 527 

Morbid anatomy. Symptoms and progress. Treatment. 

E. Obstruction and Dilatation of Lymphatics ....... 528 

Morbid anatomy. Symptoms and progress. Treatment. 

VI. Leucocythjemia (Leukcemia) 529 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

VII. Idiopathic Anaemia. Chlorosis 531 

Definition. Causation. Symptoms and progress. Pathology. Treat- 
ment. 

VIII. Purpura •. . . . . . . . . . .535 

Definition. Causation. Symptoms and progress. Varieties. Mor- 
bid anatomy. Treatment. 

IX. Scurvy (Scorbutus) 537 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

[Haemophilia. Hemorrhagic Diathesis. {Bleeder Disease) . . 540 
Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. ] 

X. Chronic Alcoholic Poisoning (Alcoholism). Delirium 

Tremens . . 545 

Nervous Disorders. Delirium Tremens ....... 546 



Causation. Symptoms. Pathology and morbid anatomy. Treat- 
ment. 



xxiv 



CONTENTS. 



PAGE 

XI. Chronic Lead-Poisoning (Plumbism). Colic. Dropped 

Hand 550 

Causation. Symptoms and progress. A. Lead colic. B. Nervous 
disorders. Dropped hand. Pathology and morbid anatomy. Treat- 
ment. 

XII. Chronic Mercurial Poisoning (Mercurialism) . . . 555 
Causation. Symptoms and progress. Morbid anatomy. Treatment. 



Chap. V. — DISEASES OF THE DIGESTIVE ORGANS 557 

Section I Diseases of the Mouth, Fauces, and Adjacent 

Parts ........ ..... . . . 557 

I. Catarrh 557 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

II. Thrush (Aphtha) 560 

Causation and morbid anatomy. Oidium albicans. Symptoms and 
progress. Treatment. 

III. Ulcerative Stomatitis . 562 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

IV. Noma (Gangrenous Stomatitis). Gangrene of Fauces . 563 

A. Noma. Causation. Morbid anatomy, Symptoms and progress. 
B. Gangrene of fauces. Causation. Symptoms and progress. C. 
Treatment. 

V. Inflammation of the Gums in Dentition . . . .564 

VI. Glossitis .... . . . . . . . . 565 

Causation. Symptoms and progress. Treatment. 

VII. Quinsy (Tonsillitis) 566 

A. Acute Tonsillitis . 566 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

B. Chronic Tonsillitis . . . . . . . . .568 

Symptoms and progress. Treatment. 

VIII. Retro-Pharyngeal Abscess 569 

Causation. Symptoms and progress. Treatment. 

IX. Ozoena ..... . . . . . . .569 

Causation. Symptoms. Treatment. 

X. Morbid Growths 570 

A. Tubercle. B. Syphilis. C. Malignant tumors. Treatment. 



CONTENTS. XXV 

PAOB 

Section II. — Diseases of the GEsophagus . . 571 

I. Introductory Remarks 571 

Anatomical Relations . . . . • • • • • .571 

II. Inflammation of the (Esophagus . . . . . . 572 

Causation and morbid anatomy. Symptoms. 

III. Chronic and Obstructive Diseases of the (Esophagus 572 

A. Ulceration .... 572 
Causation and morbid anatomy. 

B. Morbid Growths 573 

Morbid anatomy. 

C. Affections implicating the (Esophagus from without .... 574 
Causation and morbid anatomy. 

D. Dilatation 574 

Causation and morbid anatomy. 

E. Spasm and Paralysis . . . . . . . . .574 

F. Symptoms. Dysphagia . . . . . . . • .575 

G-. Treatment . . . . * . . . . 577 

Section III Diseases of the Stomach, Intestines, and Pe- 
ritoneum 578 

I. Introductory Remarks 578 

A. Anatomical Relations ......... 578 

B. Examination of the Abdomen ........ 578 

1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 

II. Gastritis 581 

Causation. Morbid anatomy. Symptoms and progress. Varie- 
ties. Treatment. 

III. Enteritis . 585 

Causation. Morbid anatomy. Varieties. Symptoms and pro- 
gress. Treatment. 

IV. Ulceration of the Stomach 590 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

V. Ulceration of the Bowels 593 

Causation and morbid anatomy. Varieties of ulcer. Symptoms 
and progress. Treatment. [Duodenal ulcers. Symptoms and pro- 
gress. Treatment.] 

VI. Perforating Ulcers of the C^cum and Rectum . . 599 

A. Typhlitis, Perityphlitis . . . . . . . . 599 

Causation and morbid anatomy. Symptoms and progress. 

Treatment. 

B. Periproctitis . . . . . . . . .601 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 



xxvi 



CONTENTS. 



PAGE 

VII. Dysentery . 602 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

VIII. Peritonitis 608 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

IX. Cirrhosis of the Stomach and Bowels .... 614 
Morbid anatomy. Symptoms. 

X. Tubercle {Abdominal Phthisis) 614 

Morbid anatomy. 1. Bowels. 2. Peritoneum and abdominal lym- 
phatic glands. Symptoms and progress. 1. Bowels. 2. Perito- 
neum. Treatment. 

XI. Tumors 618 

A. Non-malignant Tumors . . . . . . . . .618 

Polypi, villous growths. 

B. Malignant Tumors .......... 619 

Morbid anatomy. 1. Scirrhous cancer. 2. Colloid. 3. Encephaloid 
4. Epithelioma. 5. Adenoid cancer. 6. Sarcoma and lymphadema. 
Symptoms and progress. 1. Stomach. 2. Bowels. 3. Peritoneum 
and glands. Treatment. 

XII. Parasitic Affections 626 

A. Tapeworms and Cyst-ivorms (Cestoda or Tceniada) . . . . 626 

1. General account. 

2. Taenia Solium, Tcenia Medio canellata, and Bothriocephalus Latus . . 627 

Symptoms. Treatment. 

3. Taznia Echinococcus. Hydatid ........ 629 

B. Round Worms (Ncematoda) ......... 631 

1. General account. 

2. Common Round Worms {Ascaris Lumbricoides) ..... 632 

Symptoms. Treatment. 

3. Common Thread- Worms or Seat- Worms ( Oxyuris Vermicularis) . . 633 

Symptoms. Treatment. 

4. Whip- Worms ( Trichocephalus Dispar) ....... 633 

5. Dochmius Duodenalis {Sclerostoma Duodenale) ..... 634 

6. Trichina Spiralis. Trichinosis ........ 634 

Symptoms and progress. Treatment. 

7. Filaria Sanguinis Ho minis . . . . . . . . 636 

XIII. Degenerative Affections of the Stomach and 

Bowels 638 

XIV. Obstruction of the Stomach . . . . . . 638 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 



CONTENTS. 



xxvii 



PAGE 



XV. Obstruction of the Bowels 640 

A. Constipation . . . . . . . . . . 641 

Causation, morbid anatomy, and symptoms. 

B. Stricture . . . 641 

Causation and morbid anatomy. Symptoms and progress. 

C. Compression and Traction ........ 644 

Causation and morbid anatomy. Symptoms and progress. 

D. Torsion, or Twisting . . . . . . . . . 644 

Causation and morbid anatomy. Symptoms and progress. 

E. Internal Strangulation . . . . . . . . . 645 

Causation and morbid anatomy. Symptoms. 

F. Impaction of Foreign Bodies ........ 646 

Causation and morbid anatomy. Symptoms and progress. 
Gr. Intussusception .......... 648 

Causation and morbid anatomy. Symptoms and progress. 

H. Concluding Remarks in reference to Sipnpto?ns of Obstruction . . 651 
1. Pain. 2. Vomiting. 3. Constipation. 4. Tumor and shape 

of belly. 5. Condition of urine. 6. Duration of life. 7. Statistics. 

I. Treatment ........... 653 

XVI. Ascites (Abdominal Dropsy) 655 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

XVII. Hemorrhage. H^matemesis. Mel^ena . . . 658 
Definition. Causation. Symptoms and progress. Treatment. 

XVIII. Dyspepsia (Indigestion) 661 

Definition. Causation. 1. Symptoms referable to the stomach ; 
appetite ; abnormal sensations ; flatulence and eructation ; nausea 
and sickness ; pyrosis. 2. Symptoms referable to other organs. 
Treatment, 

XIX. Diarrhoea 668 



Causation. Symptoms and progress. Treatment. Raw meat in 
treatment. 



Section IV Diseases of the Liver and Pancreas . 675 



I. Introductory Remarks . . . ' 675 

A. Anatomical Relations . . . . . . . . .675 

B. Physiological Considerations . . . . . . . .676 

C. Pathological Considerations ........ 677 

Jaundice. 

II. Inflammation of the Hepatic Ducts . . . 681 



Causation. Morbid anatomy. Symptoms and progress. Treat 
ment. 



xxvni 



CONTENTS. 



page 

III. Acute Hepatitis 682 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

IV. Cirrhosis of the Liver 687 

A. Atrophic Cirrhosis {Hobnailed or Drunkard's Liver) . . .687 

Causation. Morbid anatomy. Symptoms and progress. 

B. Hypertrophic Cirrhosis ......... 689 

Causation and morbid anatomy. Symptoms and progress. 

C. Other Conditions allied to Cirrhosis ...... 690 

Causation and morbid anatomy. 1. Syphilitic cirrhosis. 2. 
Syphilitic contraction. 3. Perihepatitis. Symptoms and progress. 

D. Treatment of Cirrhosis . . . . . . . .691 

V. Congestion of the Liver (Nutmeg Liver) . . . .691 
Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

VI. Morbid Growths 692 

A. Tubercle 692 

B. Syphilis 693 

Morbid anatomy. Symptoms. Treatment. 

C. Non-malignant Growths . . . . . . . . 694 

D. Malignant Growths ......... 694 

Morbid anatomy. Symptoms and progress. Treatment. 

VII. Hydatids of the Liver 698 

Morbid anatomy. Symptoms and progress. Treatment. 

VIII. Fatty Liver 702 

Causation. Morbid anatomy. Symptoms. Treatment. 

IX. Lardaceous Liver 703 

Causation. Morbid anatomy. Symptoms. Treatment. 

X. Gall-Stone . . . . . . . . . . .704 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

XI. Obstruction of the Hepatic Ducts 708 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

XII. Jaundice without obvious Obstruction of Ducts . 712 

Causation. Morbid anatomy. Symptoms. Treatment. 

XIII. Malignant Jaundice (Yellow Atrophy of the Liver) . . 713 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

XIV. Diseases of the Pancreas 715 

A. Introductory Remarks . . . . . . . . .715 

B. Hyperaimia and Inflammation ....... 715 



CONTENTS. Xxix 

PAGE 

C. Morbid Growth 716 

D. Calculi . . . . 716 

E. Obstruction of the Pancreatic Ducts . . . . . .716 

F. Symptoms and Treatment . . . . . . . .717 



Chap. VI.— DISEASES OF THE GENITO-URINARY 

ORGANS . . . .718 

Section I Diseases of the Kidneys . . . 718 

I. Introductory Remarks 718 

General Physiological and Pathological Considerations . . . .718 

A. Characters and Composition of the Urine ..... 719 

1. Physical characters of morbid urine. 2. Urea. 3. Uric acid 
and urates. 4. Xanthine. 5. Cystine. 6. Leucine, and tyrosine. 7. 
Coloring matters. 8. Odorous matters. 9 Grape sugar. 10. Amorphous 
phosphate of lime. 11. Crystallized phosphate. 12. Ammoniaco-mag- 
nesian phosphate. 13. Oxalate of lime. 14. Carbonate of lime. 15. 
Albumen. 16. Blood. 17. Bile. 18. Casts. 19. Mucus and pus. 
20. Fat. 21. Morbid growths. 22. Spermatozoa. 23. Animal and 
vegetable organisms. 

B. Concretions ........... 732 

1. Uric acid. 2. Uratic. 3. Cystine. 4. Xanthine. 5. Oxalate 
of lime. 6. Amorphous phosphate and ammoniaco-magnesian phosphate. 
7. Carbonate of lime. 8. Blood, indigo, Sfc. 

C. The Specific Consequences of the Retention of Urea and other matters 

in the Blood . . . • . . 733 

1. Thickening and contraction of the smaller bloodvessels. 2. 
Hypertrophy of the heart. 3. Anasarca and other dropsical effu- 
sions. 4. Congestions and hemorrhages. 5. Inflammatory affec- 
tions. 6. Functional consequences. 

D. The Non-specific Morbid Phenomena which attend on and characterize 

Lesions of the Kidneys . . . . . . . .736 

II. Pyelitis 736 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

III. Circumscribed and Suppurative Nephritis . . . 739 

Causation. Morbid anatomy. Symptoms. Treatment. 

IV. Acute Bright's Disease {Acute Albuminous, Desquamative, 

or Tubal Nephritis) . 740 

Causation. Morbid anatomy. Varieties. Symptoms and progress. 
Treatment. 

V. Chronic Bright's Disease . 744 

A. Chronic Parenchymatous or Tubal Nephritis {Large White Kidney, and 

Fatty Kidney) 744 

Causation. Morbid anatomy. Symptoms and progress. 



XXX 



CONTENTS. 



PAGE 

B. CJironic Interstitial Nephritis {Contracted Granular Kidney. Gouty 



Kidney) . . . . 746 

Causation. Morlbid anatomy. The cystic kidney. Symptoms 
and progress. 

C. Treatment of Chronic Bright' 1 s Disease . . . . . 750 

VI. Congestion op the Kidney 751 

Causation. Morbid anatomy. Symptoms. Treatment. 

VII. Tubercular Disease of the Kidney .... 752 
Morbid anatomy. Symptoms and progress. Treatment. 

VIII. Syphilitic Disease of the Kidney 753 

IX. Morbid Growths of the Kidney 753 



Morbid anatomy. 1. Lymphadenoma. 2. Sarcoma. 3. Carcinoma. 
Symptoms and progress. Treatment. 

X. Parasitic Affections of the Kidney .... 755 
A. Hydatid cysts. Treatment. B. Bilharzia hcematobia. Treatment. 



XI. Lardaceous Degeneration of the Kidney . . . 756 
Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

XII. Gravel and Renal Calculi 757 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

XIII. Hydro-Nephrosis and Atrophy of the Kidney . . 760 
Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

XIV. Misplaced and Movable or Floating Kidneys . . 761 
Causation and morbid anatomy. Symptoms. Treatment. 

XV. Chyluria . . .762 

Causation and symptoms. Pathology. Treatment. 

XVI. HEMATURIA 764 

Causation and symptoms. Treatment. 



XVII. Paroxysmal Hematuria (Paroxysmal Hcematinuria) . 764 
Definition. Causation. Symptoms and progress. Pathology. 



Treatment. 

XVIII. Diabetes (Diabetes Mellitus. Glycosuria) . . . 766 
Definition. Causation. Symptoms and progress. Morbid anatomy 
and pathology. Treatment. 

XIX. Diabetes Insipidus (Diuresis) 772 

Causation. Symptoms and progress. Morbid anatomy. Treat- 
ment. 

XX. Suppression of Urine (Ischuria Renalis) . . . 773 



A. Functional suppression of urine. B. Suppression of urine from 
obstruction. Symptoms and progress. Treatment. 



CONTENTS. XXxi 

PAGE 

Section II Diseases of the Pelvic Organs . . 774 

I. Diseases of the Urinary Bladder 774 

1. Inflammation . . . . . . • • • • 774 

Symptoms. Treatment. 

2. Tubercle 775 

3. Morbid growths . . 775 

4. Dilatation 775 

Symptoms. Treatment. 

II. Diseases of the Uterus, Fallopian Tube and Ovaries . 776 

A. Metritis and Oophoritis . . . . . • . . . 776 

Causation and morbid anatomy. Symptoms. 

B. Morbid Growths . 777 

1. Tubercle. Symptoms. 2. Myomata. Symptoms. 3. Malignant 
disease. Symptoms. 

C. Cystic Tumors 778 

Causation and morbid anatomy. 1. Dilatation of the uterus. 2. 
Dilatation of the Fallopian tube. 3. Ovarian cysts. Symptoms and 
progress. Treatment. 

III. Diseases of the Pelvic Peritoneum and Connective 

Tissue 781 

Chap. VII — DISEASES OF THE ORGANS OF LOCOMO- 
TION .......... 783 

I. Rheumatism {Rheumatic Fever) . 783 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

II. Rheumatoid Arthritis {Chronic Rheumatic Arthritis) . 791 
Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

III. Gout {Podagra) . . . 793 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

IV. Rickets {Rachitis) 801 

Definition. Causation. Morbid anatomy and pathology. Symptoms 
and progress. Treatment. 

V. Mollities Ossium {Osteo-malacia) 808 

Definition and causation. Morbid anatomy and pathology. Symp- 
toms and progress. Treatment. 



xxxii 



CONTENTS. 



PAGE 

Chap. VIII DISEASES OF THE NERVOUS SYSTEM . 810 

I. Introductory Remarks 810 

A. Anatomy and Physiology ......... 810 

1. Membranes of brain and cord. 2. Ventricles of brain and cord. 
3. Cerebral hemispheres : a. fissures ; b. convolutions. 4. Ganglia at 
base of brain. 5. Cerebellum and its peduncles. 6. Spinal cord. 
7. Medulla oblongata. 8. Cerebro-spinal nerves. 9. Resume. 10. 
Localization of function : a. cerebral hemisphere ; b. corpus striatum ; 
c. optic thalamus ; d. cerebellum; e. corpora quadrigemina ; /. medulla 
oblongata; g. cord; h. olfactory and optic nerves. 11. Sympathetic 
system. 12. Arteries of brain. 13. Veins of brain. 

B. Pathology 831 

1. Motor Paralysis. Paresis 831 

a. Cerebral paralysis, i. General paralysis, ii. Hemiplegia. b. 
Bulbar paralysis, c. Spinal paralysis — paraplegia, d. Nerve paralysis, 
e. Diseases of the cerebellum, f. Condition of muscles in motor jiaralysis. 
i. Tone. ii. Contractility and irritability, iii. Faradic sensibility, 
iv. Nutrition, v. Reflex action. 

2. Anaesthesia . . . . . . . ... . . 838 

a. Cerebral ancesthesia. i. General anaesthesia, ii. Hemianesthesia. 
b. Bidbar ancesthesia. c. Spinal ancesthesia. d. Nerve anaesthesia. 

3. Convulsions. Spasms . . . . . . . . . 840 

4. Hyperesthesia. Dysesthesia . . . 842 

5. Influence of Nervous Diseases over the Nutritive Processes . . . 843 

a. Sympathetic system. b. Cerebro-spinal system, i. Muscles, ii. 
Joints and bones, iii. Skin ; bed-sores, iv. Viscera. Recapitulation. 

6. Ascending, Descending, and Collateral Lesions ..... 848 

7. Central and Reflex Consequences of Lesions of the Nerves . . 849 

8. Headache 849 

9. Vertigo 850 

10. Impairment and Loss of Power of Speech (Aphasia. Aphemia. Amnesia) 851 

Varieties. 

11. Mental and Emotional Disturbances . . . . . . .856 

C. Electricity in Nervous Diseases . . . . . . . .857 

For diagnostic purposes. Therapeutic uses. 

II. Inflammation of the Cerebral and Spinal Dura Mater. 

Pachymeningitis 860 

Causation. Morbid anatomy: 1. Cerebral dura mater; 2. Theca 
vertebralis ; 3. Pachymeningitis. Symptoms and progress ; 1. Acute 
inflammation of the cerebral dura mater ; 2. Pachymeningitis of the 
cerebral dura mater ; 3. Acute general inflammation of the theca ver- 
tebralis ; 4. Caries of the vertebra?; 5. Cervical pachymeningitis. 
Treatment. 



CONTENTS. 



xxxiii 



PAGE 

III. Cerebral and Spinal Meningitis. Tubercular Menin- 
gitis. (Acute Hydrocephalus) 868 

Causation. Morbid anatomy : 1. Cerebral meningitis ; 2. Tuber- 
cular meningitis ; 3. Spinal meningitis. Symptoms and progress : 1. 



Cerebral meningitis ; 3. Spinal meningitis. Treatment. 
IV. Encephalitis and Myelitis .876 

(Inflammation and Suppuration of the Brain and Cord.) 

Causation. Morbid anatomy : 1. Encephalitis; 2. Myelitis. Symp- 
toms and progress : 1. Encephalitis ; 2. Myelitis. Treatment. 

V. Sclerosis (Chronic Inflammation) 882 

A. Infantile Spinal Paralysis (Infantile Paralysis) • • • ' .884 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

B. Adult Spinal Paralysis ......... 887 

C. General Spinal Paralysis ......... 888 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

D. Progressive Muscular Atrophy ( Wasting Palsy) ..... 889 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

E. Lateral Sclerosis .......... 892 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

F. Tabes Dorsalis (Locomotor Ataxy) . . . . . . .896 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

G. Glosso-labio-laryngeal Palsy . . . . . • . . . 902 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

H. Disseminated Sclerosis (Multiple Sclerosis) ...... 905 



Definition. Causation. Morbid anatomy. Symptoms and progress : 
1. Rhythmical tremors ; 2. Affections of the eyes ; 3. Defect of speech ; 
4. Vertigo; 5. Paresis of limbs ; 6. Contraction of limbs ; 7. Expres- 



sion and mental condition. Stages. Treatment. 

VI. Paralysis Agitans - 910 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

VII. Pseudo-Hypertrophic Paralysis 914 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

VIII. Morbid Growths. Aneurisms. Entozoa . . .916 



Morbid anatomy : 1. Tubercle; 2. Syphilis; 3. Neoplasms; a. myxoma; 
b. glioma; c. sarcoma; d. carcinoma; 4. Entozoa; a. cysticerci ; b. 
hydatids ; 5. Aneurisms. Symptoms and progress : 1. Brain ; Vertigo ; 
C 



xxxiv 



CONTENTS. 



PAGE 

headache ; vomiting ; slowness of pulse ; hemiplegia and hemianes- 
thesia ; local paralyses ; implication of sensory nerves ; convulsions 
and spasms ; intellectual and emotional disorders ; obstruction of 
venous sinuses. 2. Spinal cord: a. in substance of cord; b. in me- 
ninges. Treatment. 

IX. Cerebral and Spinal Hemorrhage (Apoplexy) . .926 
Causation. Morbid anatomy : 1. hemorrhage on surface ; 2. hemor- 
rhage into the brain : 3. into the cord. Symptoms and progress : 1. 
in cerebral hemorrhage ; 2. in spinal hemorrhage. Treatment. 

X. Obstruction of Cerebral Arteries (Thrombosis. Em- 
bolism. Softening} 935 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

XI. Hydrocephalus and Hydrorrhachis (Cerebral and 

Spinal Dropsy) 939 

Causation and morbid anatomy : 1. a. Hydromeningocele, hydren- 
cephalocele; b. Sjnna bifida; 2. a. Chronic hydrocephalus; b. Internal 
hydrorrhachis. Symptoms and progress. Treatment. 

XII. Chorea (St Vitus 9 s Dance) . . . ... . 945 

Definition. Causation. Symptoms and progress. Morbid anatomy 
and pathology. Treatment. 

XIII. Epilepsy. Eclampsia. Infantile Convulsions . . 951 

A. Epilepsy (Morbus comitialis vel sacer} ...... 951 

Definition. Causation. Symptoms and progress. Description of 
epilepsia gravoir or the haut mat. Description of abortive fit and of the 
petit mal or epileptic vertigo. The status epilepticus. Recurrence of fits. 
Causes determining the occurrence of fits in epileptics. Condition of 
epileptics in intervals between the attacks. Epileptic mania. Diag- 
nosis. Feigned epilepsy. Morbid anatomy and pathology. Treat- 
ment. 

B. Eclampsia ............ 962 

Definition and causation. Symptoms and progress. Treatment. 

C. Infantile Convulsions . . . . . . . . . .963 

Definition and causation. Symptoms and progress. Treatment. 

XIV. Hysteria . 965 

Definition. Causation. Symptoms and progress : 1. Convulsions 
and spasms ; 2. Hyperesthesia ; 3. Anesthesia ; 4. Paralytic condi- 
tions ; 5. Affections of the larynx and air-passages ; 6. Affections of 
the alimentary canal ; 7. Affections of the urinary organs : 8. Affec- 
tions of the reproductive system ; 9. Affections of the spine, joints, 
and mammse ; 10. Spinal irritation. Diagnosis. Pathology. Treat- 
ment. 



CONTENTS. 



XXXV 



PAGE 

XV. Catalepsy, Ecstasy, and other Conditions allied to 

Hysteria 975 

1. Rhythmical and other Methodical Movements ...... 976 

2. Catalepsy 976 

3. Ecstasy 976 

4. Double-consciousness . . . . . . . . . .977 

Treatment. 

XVI. Tetanus (Trismus. Lock-jaw') 977 

Definition. Causation. Symptoms and progress. Trismus, or lock- 
jaw. Opisthotonos. Emprosthotonos. Pleurosthotonos. Diagnosis. Mor- 
bid anatomy. Treatment. 

XVII. Congestion. Anaemia. Sunstroke . . . .981 

A. Congestion and Ancemia . . . . . . . . 981 

Symptoms : 1. Delirium tremens. 2. Insanity. 3. Eclampsia. 4. 
Apoplexy and paralysis. Treatment. 

B. Sunstroke {Coup de Soleil. Calenture. Insolatio) . . . .984 

Definition. Causation. Symptoms and progress. Morbid anatomy 
and pathology. Treatment. 

XVIII. Megrim (Migraine. Hemicrania. Sick-headache) . 986 
Definition. Causation. Symptoms and progress. Patliology. Treat- 
ment. 

XIX. Meniere's Disease (Aural Vertigo) 989 

Definition. Causation and pathology. Symptoms and progress.- 

Treatment. 

XX. Local Paralyses 991 

A. Paralysis of the Third, Fourth, and Sixth, or Oculo-Motor Nerves . . 991 

Causation. Symptoms and diagnosis. Treatment. 

B. Paralysis of the Fifth Nerve . . . . . . . 995 

Causation. Symptoms and diagnosis. Treatment. 

C. Paralysis of the Portio Dura {BelVs Paralysis) . . . . .996 

Causation. Symptoms and diagnosis. Treatment. 

D. Paralysis of the Spinal Nerves . . . . . . . .999 

Causation. Symptoms and diagnosis : 1. Deltoid rheumatism ; 
2. Paralysis of musculo-spinal nerve. Treatment. 

XXI. Local Functional Spasm and Paralysis. Writer's 

Cramp, Wry-Neck, Histrionic Spasm, &c. . . 1001 
Definition. Causation. Symptoms and diagnosis : 1. Writer's 
cramp ; 2. Spasmodic wry-neck, &c. Pathology. Treatment. 

XXII. Neuralgia. Tic Douloureux. Sciatica . . . 1003 
Definition. Causation. Symptoms and progress : 1. Tic doulou- 
reux; 2. Sciatica and other forms. Treatment. 

XXIII. Insanity 1008 

Definition. Causation. Pathology and morbid anatomy. Varie- 
ties. Symptoms and Progress. Treatment. 

Index 1045 



xxxvi 



CONTENTS. 



LIST OF DIAGRAMS. 



PAGE 



Fig. 1.— Pulse Trace . . 438 

" 2.— Pulse Trace . . . • . . . . . . .439 

" 3. — Lateral View of Brain, showing Principal Convolutions and 

Fissures {after Ecker) . . . . . . . . 813 



" 4. — Inner Surface of Cerebral Hemisphere, showing Principal Con- 
volutions and Fissures (after Ecker). It likewise shows Fer- 
rier's Centre of Touch and of Smell and Taste . • . 813 

" 6. — Lateral View of Brain, showing Ferbier's Centres of Move- 
ments (after Ferrier) . . ... . . . .. . . 822 

" 6. — Upper Aspect of Brain, showing Principal Convolutions and Fis- 
sures ; AND ON THE LEFT SlDE FeRRIER'S CENTRES OF MOVEMENTS, 

and on the Right the Arterial Are.e (after Ecker, Ferrer, and 

Charcot) 822 

" 7. — Scheme of Decussation of Optic Tracts (after Charcot) . . 826 

" 8. — Lateral View of Brain, showing Arterial Are2e . . . 828 
" 9. — Inner Surface of Cerebral Hemisphere, showing Arterial Are^e 

(after Charcot) 828 

" 10. — Under Surface of Brain, showing Principal Convolutions and 

Fissures and Arterial Areje (after Charcot) . ' . . . 829 
' ' 11. — Portrait of a Boy Suffering from Pseudo-Hypertrophic Paralysis 915 
" 12. — Horizontal Section of Eye, showing Axes of Rotation . . 992 
" 13. — Anterior View of Eyeball, showing the Direction of the Move- 
ments EFFECTED BY ITS SEVERAL MUSCLES 993 

" 14, 15, 16, 17, 18, 19. — Diagrams showing Relations of True to False 

Image in Different Varieties of Squint ..... 994 



THE 

PRACTICE OF MEDICINE. 



PART I. 
GENERAL PATHOLOGY. 



I. THE DEFINITION OF DISEASE. 

Pathology, or the physiology of disease, is the science of life under 
morbid or abnormal conditions. This science, and the arts of applying it 
in the detection and in the alleviation or cure of disease, and in its pre- 
vention, form the subject-matter of works on medicine and surgery. 

The question, then, 'What is disease?' naturally arises on the very 
threshold of a treatise on the practice of medicine. But although doubt- 
less every physician has a notion, sufficiently clear for the practical pur- 
poses of his art, of what is implied in the word, the question is one which 
by no means admits of a ready and explicit answer. Disease, in some at 
least of its forms, has been regarded by many persons, and is probably still 
regarded by some, as a real tiling or entity. This view implies that it can 
be either cut out by the anatomist, or extracted by the chemist, or excreted 
by the patient himself, or in some other way separated from his body, so 
as to become capable of independent existence and recognition ; and might 
be supported by reference to the discharge of an intestinal worm or the 
removal of a vesical calculus, or to a patch of psoriasis, an epitheliomatous 
tumor, a malformed heart, or probably any other so-called ' local' disease. 
A little thought, however, will satisfy the mind that the intestinal worm, 
or the calculus, is of itself the mere cause of disease, and not disease ; and 
that the patch of psoriasis, the epitheliomatous tumor, or the malformed 
heart, is simply a morbid fragment of the body, and no more the disease 
itself than the patient who is suffering from scarlet fever or syphilis is the 
actual embodiment of either of these latter two affections. But, indeed, 
the opinion that disease is an entity has now been abandoned by all 
thoughtful physicians. Another view of disease is,, that it consists in any 
deviation from the healthy state, or (at greater length) in any condition 
of the entire system, or of any part of it, attended with impairment or 
derangement of structure or function, or both, and tending to render life 
uneasy, burdensome, or useless, or to shorten it. It would be difficult 
perhaps to dispute the accuracy of this definition so far as it goes ; at the 
3 



34 



THE DEFINITION OP DISEASE. 



same time it is obvious that Ave gain nothing by it unless we have previ- 
ously agreed upon a definition of health ; and in fact, by accepting it, we 
simply shirk the difficulty which we pretend to solve. 

If we consider attentively the various morbid processes and symptoms 
which separately or in combination indicate the presence of disease, and 
trace them in each case backwards to their origin, we cannot avoid the 
conclusion that that origin is some definite or peculiar cause, either innate 
in the system or acting on it from without, and determining according to 
its nature and its mode of operation the character and the grouping of the 
morbid phenomena which ensues — in other words, that the biography of 
every disease comprises some special cause, and certain resultant pheno- 
mena (vital, chemical, or mechanical) which are, or which produce, the 
symptoms and signs by which we recognize its presence. Let us test the 
accuracy of this view of disease by a few examples. 

A patient is suffering from scabies or tinea tonsurans. In the one case 
his epidermis is traversed by a lowly form of vegetable growth, and the 
seats of this growth are indicated by rings of superficial inflammation, by 
desquamation and the destruction of hair ; in the other case, his epidermis 
is undermined by the burrows of swarming acari, which produce local 
irritation with intolerable itching, and involve the formation of vesicles 
and pustules. Now in each of these examples we have an obvious cause, 
and certain resultant phenomena — the former being the parasite, the latter 
certain localized inflammatory processes. We have the two factors : 
namely, the cause and its consequences. We have also the disease. But 
where is it, and what is it ? Is it the parasite, the presence of which is 
essential in order that the disease shall present its specific characters ? Is 
it the inflammation which the presence of the parasite evokes ? The an- 
swer to both of these questions must surely be in the negative. The para- 
site away from the body in which it resides, or apart from the irritation 
which it causes, is simply a living member of the animal or vegetable 
kingdom ; the local inflammation, dissociated from its specific cause, is 
inflammation, if you will, but neither scabies nor ring-worm. Obviously 
then, as applied to such cases as these, the word disease (if it have any 
real meaning) includes both the special cause of the disease, and the patho- 
logical consequences of the operation of that cause. 

Again, a person who has never had scarlet fever inhales the particles, 
or the * contagium,' which is the specific cause of scarlet fever, and forth- 
with becomes the subject of that disease. The contagium multiplies within 
his system, and presently a characteristic rash overspreads his surface ; 
his tonsils and probably his kidneys become inflamed ; and, in association 
with these conditions, there is profound disturbance of his nutritive pro- 
cesses, indicated by heightened temperature, increased formation of urea, 
and many so-called 1 functional derangements.' Now here again we have 
the cause of the disease, and the various morbid processes which result 
from its operation. But where is the disease ? What is meant by the 
term 'scarlet fever?' The specific contagious particle of scarlet fever 
gives scarlet fever, exactly as the acarus scabiei gives itch, or the tricho- 
phyton tonsurans gives ringworm : a group of mutally-related phenomena 
spring up in obedience to their cause as invariably in the former case as 
in the latter cases. But the contagium of scarlet fever may, as we know, 
gain an entrance into the living body, and yet belnoperative there ; and, 
on the other hand, several of the more prominent phenomena which form 
a part of scarlet fever, or symptoms which seem to us identical with the 



THE DEFINITION OF DISEASE. 



35 



corresponding symptoms of scarlet fever, are occasionally combined in per- 
sons who are certainly not suffering from this exanthem. Yet, obviously, 
in neither of these cases is scarlet fever present. In the former case, the 
host remains healthy ; in the latter case, the disease, though presenting 
some points of superficial resemblance to scarlet fever, is potentially and 
essentially distinct from it. Here also, then, it is obvious that, when we 
speak of the disease, we include in our meaning, not only the symptoms 
by which we recognize its presence, but the cause upon which those symp- 
toms depend. 

Let us take another case. A man is exposed to cold and wet, and 
shortly afterwards one of his joints becomes swollen and painful ; febrile 
symptoms, attended with abundant sour-smelling perspirations, manifest 
themselves ; presently inflammation attacks other joints ; perhaps too the 
heart becomes implicated. We have here a lot of symptoms which col- 
lectively teach us that the patient is suffering from the disease known as 
' acute rheumatism.' But what is acute rheumatism ? Mere inflamma- 
tion of a joint, such as that which results from a sprain, does not constitute 
it ; nor even do successive or simultaneous attacks of inflammation of 
several joints — for if they did, both gout and pyaemia should be embraced 
within its meaning. Still less are high temperature and profuse perspira- 
tions rheumatism ; still less acute heart-disease, or any of its various other 
inflammatory complications. Further, the merely fortuitous concurrence 
of most, or even all, of the symptoms which have just been enumerated 
would still not render the case in which they occurred a case of rheuma- 
tism. Something more is required for that purpose : a something which 
shall link all the symptoms together into a common brotherhood, a some- 
thing which shall constitute their common parentage, a cause from which 
all shall have directly or indirectly sprung, and which shall have impressed 
upon them their separate and collective peculiarities. Whether that cause 
consist in some chemical or other change directly effected in the blood 
flowing through the part exposed to cold, or in some similar change (in- 
duced through the agency of the sympathetic nerves) in connection with 
the joints themselves, whether the precise nature of the cause be known or 
unknown, is immaterial for our argument. In this case, as in the other 
cases which have been quoted, a cause undoubtedly is or has been in 
operation ; and independently of it the disease 1 rheumatism' has no 
existence. 

The relation between cause and effect in disease, and the necessity for 
not overlooking the cause as an essential part of the disease, are nowhere 
more obvious than where we have to do with affections in which the cause 
is tangible, or admits of being weighed, measured, or otherwise tested or 
examined ; as, for example, where mechanical impediments occur in the 
course of the bowel, urethra, ducts of glands, and other tubular organs ; 
or where poisons received into the stomach act directly upon that viscus, 
or on distant organs in which they are deposited, or through which they 
circulate ; or where, finally, pathological results follow from excess, defi- 
ciency, or unwholesomeness of diet. 

Now, in every one of the above examples, it is beyond dispute that 
neither the collective morbid phenomena or symptoms which indicate the 
presence of disease, taken by themselves, nor the morbid cause on which 
these phenomena depend, taken by itself, constitute a disease ; that, alone, 
they are simply factors of disease ; and that in each case our conception 
of a disease is fulfilled only when the cause and its results are, so to speak, 



3(3 



THE ETIOLOGY OF DISEASE. 



welded mentally into one common whole. And hence, if these views be 
generally true, disease may be defined as a complex of some deleterious 
agency acting on the body, and of the phenomena [actual or potential} due 
to the operation of that agency. 

Regarding it, not as a matter of idle curiosity, but as one of funda- 
mental importance for a clear appreciation of the aims and limits of diag- 
nosis and treatment, that we should have a distinct comprehension of what 
we mean by disease, we shall pursue the question yet further, mainly with 
the object of determining how far the word disease is properly applicable 
(as it often is applied in practice) to mere symptoms or secondary pheno- 
mena or incidents of disease. 

All diseases involve, some in a greater, some in a lesser degree, certain 
groups of pathological consequences immediately traceable to their respec- 
tive morbid causes; but these primary pathological consequences themselves 
tend to evoke others, these again a tertiary series, and so on continuously. 
Thus, a person with carcinoma of the bowel may, as a consequence, have 
stricture, or perforation, or involvement of the glands occupying the retro- 
peritoneal tissue and gastro-hepatic omentum, or that form ' of cachexia 
which cancerous disease so frequently induces ; and, as a consequence of 
these several secondary morbid conditions, various other affections, such as 
enteritis, peritonitis, jaundice, ascites, mehena, thrombosis or anasarca. 

Now all these phenomena, and many others, are obviously integral por- 
tions of the carcinomatous affection from which the patient is suffering, 
and all of them may be regarded as symptoms or incidents of that affection ; 
but many of them are not unfrequently also looked upon as quasi-indepen- 
dent diseases, and treated as such. There is no doubt that they are not 
diseases. They are clearly, however, elements of disease ; and inasmuch 
as each one of them arises out of some immediately antecedent abnormal 
condition which is its direct cause, they do obviously enough, in association 
with their respective causes, fall severally within our definition of disease. 
Hence the affection which has been selected for illustration, and manifestly 
also all other primary diseases, may be considered to comprise or involve 
a number of what, regarded from one point of view, are symptoms or phe- 
nomena which are essential parts of it, regarded from another point of 
view, are component parts or factors of secondary or subordinate diseases, 
issuing in collateral lines of descent from a common ancestral cause. 



II. THE AETIOLOGY OF DISEASE. 

The causes of disease have been divided by authors into three classes, 
namely, the predisposing, the exciting, and the proximate : the first class 
comprising those conditions which so modify the health of the patient as 
to render him apt, or predispose him, to contract the disease, to the specific 
influence of which he happens to be exposed ; the second, those causes 
which immediately impart or excite disease, and give it its specific cha- 
racter; the third, those morbid processes which the action of the exciting 
cause calls into play, and to which the symptoms of disease are supposed to 
be directly due. The proximate cause indeed is often, though erroneously, 
said to be the disease itself. We will illustrate the above distinctions by 



PREDISPOSING CAUSES OF DISEASE. 



37 



an example. A woman, who has frequently been exposed to the contagion 
of scarlet fever without taking the disease, is again exposed at the period 
of childbirth, and now suffers from a virulent attack. Here, parturition, 
which renders women peculiarly susceptible of the contagious fevers, is the 
predisposing cause, the scarlatinal contagium is the exciting cause, and the 
inflammatory processes going on in the skin, tonsils, and elsewhere, the 
proximate causes of most of the symptoms which the patient manifests. 
But the exciting cause of the scarlet fever is obviously the proximate cause 
of that disease, and the proximate causes of its several secondary pheno- 
mena are just as obviously their exciting causes. 

The distinction between the exciting cause and the proximate cause is 
thus purely artificial. That between the predisposing cause and the ex- 
citing cause, on the other hand, is in general well marked ; and doubtless 
if we had an accurate knowledge of the causation of disease, the univer- 
sality of the truth which underlies these terms would be quite beyond dis- 
pute. As it is, however, doubts or difficulties as to their meaning and 
application are apt to present themselves. 

An example will explain our meaning. A man, who has been suffering 
from privation, is exposed to malarial influence, and contracts ague. In 
this case, clearly enough, privation is the predisposing cause, malaria the 
exciting cause. But after a time the ague leaves him, and he is apparently 
restored to health ; and he continues well, until perchance from exposure 
to the weather in some non-malarious district he catches cold, and straight- 
way experiences another attack of ague. Now which in the latter case 
should be regarded as the exciting cause? The answer will probably be, 
4 Exposure to cold and wet,' an answer which necessarily implies that on 
this occasion malaria is the predisposing cause. Yet, notwithstanding, 
malaria is equally in both cases the specific cause of the disease, and acts 
(as we have no reason to doubt) in both cases in a precisely similar manner. 

On the whole, however, we mean by exciting cause the specific cause, 
or element, in disease — that cause (the contagium of an exanthem, the 
virus of rabies, the parasite of a tinea) which stamps its individuality on 
the group of morbid processes which ensue, and constitutes with them a 
definite or specific disease ; and by predisposing causes we mean those 
general, non-specific conditions which by their influence so modify the 
health of the system, or of parts of it, as to render them (so to speak) a 
specially suitable soil for the growth of certain diseases, supposing their 
germs happen to become implanted therein. 

A. Predisposing: Causes of Disease. 

"VVe shall not undertake to discuss the subject of predisposing causes at 
any length, although it is one of great importance, especially in relation to 
preventive medicine ; but shall content ourselves with enumerating and 
considering briefly some of the more important and more generally recog- 
nized amongst them. 

1. The influence of age is very remarkable. The period of growth and 
development, commencing with birth and terminating with the attainment 
of maturity, and comprising the important physiological epochs of the first 
dentition, the second dentition and the unfolding of the sexual system, is 
not only attended with a general aptitude for diseases having a special 
connection with the physiological processes (general or special) which are 



38 



THE ^ETIOLOGY OF DISEASE. 



going on then, but is liable for less obvious reasons to the attacks of various 
maladies of other kinds. In early infancy a remarkable tendency exists to 
disturbances of the alimentary canal, and to these a very large proportion 
of infantile mortality is due. Again at this time, and especially during 
the period of the first dentition, epileptiform convulsions are of peculiar 
frequency. Rickets is a disease which can manifest itself only during the 
period of growth of the osseous system, and does in fact occur during the 
first few years of childhood. It is about this time also that pseudo-hyper- 
trophic paralysis is most commonly met w T ith. True asthma generally 
comes on in childhood, and not unfrequently disappears before maturity is 
reached. Chorea aflfects in large proportion young persons between the 
ages of 8 or 9 and 15 or 16 ; and epilepsy, when not immediately traceable 
to infantile convulsions, commences very frequently about the same time. 
Acute rheumatism, again, and scrofulous diseases are disproportionately 
common in young persons. Further, some parasites, such as thread-worms 
and the trichophyton tonsurans, are peculiarly prone to affect children. 
Few special liabilities to disease mark the period of maturity, excepting 
such as are connected with difference of sex, or arise out of habits of life 
and other circumstances which have only an accidental connection with 
age. But as the decline of life approaches, and during its continuance, 
many disorders, and mainly such as are connected with the decay and 
degeneration of tissues and organs, manifest themselves. Thus the central 
nervous system becomes affected, and feebleness of mind or fatuity and 
paralyses supervene ; or the heart undergoes morbid changes, and dropsies 
and hemorrhages result ; or the vessels get weakened, and aneurisms and 
ruptures with extravasations of blood occur ; or the stomach, liver, or kid- 
neys suffer, and cease to act efficiently. Gout, too, should probably be 
included among the proclivities of advancing years. 

2. The differences in the organization of the sexes necessitate of course 
differences as regards some of the diseases to which they are respectively 
liable. It need scarcely be pointed out that in one sex we meet with dis- 
orders connected with the uterus and ovaries, disorders of menstruation, 
pregnancy, and lactation ; in the other sex affections which are peculiar 
to the male organs of generation. But besides these necessary differences, 
there are others which are far more difficult to explain and yet are nearly 
as constant. Thus, chlorosis and hysteria and nervous disorders related 
to hysteria, are the almost exclusive heritage of females. And again, 
certain other affections which occur in both sexes, are yet, for no sufficient, 
reason (so far as we can see) far more frequent in the one than in the 
other. Thus, erythema nodosum, and exophthalmic goitre, and goitre 
itself, are all far more common in females than in males. It is possible of 
course that some of these latter differences may not be due to the influence 
of sex alone. 

3. Personal peculiarities, born with the individual, and often heredit- 
ary, have an important influence over the relative liability of persons to 
disease. Children notoriously resemble their parents, not only in the 
general configuration of the body, but in features, expression, complexion, 
and mental attributes. Trivial peculiarities in the form of some feature, 
in the tone of the voice, in the quality of the laugh, small oddities of 
manner or of gesture, are perpetuated in families. It is not surprising 
therefore that malformations and other morbid conditions and tendencies 



PREDISPOSING CAUSES OF DISEASE. 



39 



to disease should be transmitted also. It is important, however, to note : 
first, that such inherited peculiarities and tendencies not unfrequently skip 
a generation, or appear as it were sporadically in families, so that, while 
out of a family of brothers and sisters some are affected and others escape, 
the affected and unaffected procreate indifferently healthy and unhealthy 
offspring ; second, that the inherited tendency to disease does not in all 
cases manifest itself in an exact reproduction of the morbid peculiarity of 
the parent ; and third, that undoubtedly in many cases peculiarities of 
constitution and special proclivities to disease appear altogether de novo. 

In some instances the morbid condition is developed, or appears, in foetal 
life ; in others the child is born healthy, but with a tendency to disease, 
which becomes realized at some later period. As examples of the former 
case may be enumerated congenital malformations, idiocy, naevi. Exam- 
ples of the latter case are more common and far more important for the 
physician, and therefore need more detailed consideration. Certain func- 
tional nervous disorders, such as insanity, epilepsy, hysteria, asthma, neu- 
ralgia, undoubtedly run in families, and are apt in some degree to alternate, 
so that a parent suffering from one of them may beget children in whom 
one or other of the remaining members of the group replace as it were 
the particular parental malady. Again, gout, tuberculosis, carcinoma, and 
other forms of growths, all manifest a tendency to hereditariness. So do 
many varieties of skin-diseases, such as ichthyosis, psoriasis and acne. 
Degenerative affections, especially those which are characterized by fatty 
or calcareous changes, also have a tendency to repeat themselves ; and 
thus, in some families the members are apt to be cut off prematurely by 
extravasations of blood in the brain, due to such degeneration of the cerebral 
arteries ; in others the heart appears to be the selective seat of such changes. 
Lastly, among inherited or personal peculiarities, we must not forget cer- 
tain idiosyncrasies characterized by special aptitude to suffer from agencies 
which are to most persons innocuous, or to remain unaffected by conditions 
which are generally inimical. The influence of the emanations from fresh 
hay in producing hay-asthma and the smell of many flowers in creating 
nausea, the specially poisonous effects which even the smallest doses of 
mercury, opium, or other drugs, and which also certain forms of food 
(even such wholesome meat as mutton) have, upon certain individuals, 
the unhappy tendency which some persons seem to have to contract all the 
catching diseases to which they are exposed, and even to take the same 
one over and over again, and the remarkable way in which other persons 
seem always to escape, are common examples of the peculiarities referred to. 

4. Occupation, habits of life, quality of food or drink, over-indulgence, 
privation, and even abstinence, are all of them potent agents in modifying 
the constitution and rendering the frame susceptible of disease. We 
may quote in exemplification of this statement the acquired proclivity of 
compositors to tubercular phthisis; that of persons who lead sedentary 
lives to suffer from indigestion and constipation, and the effects of accu- 
mulated fat ; and that of habitual eaters or drinkers to excess to become 
gouty, and to suffer from renal and hepatic disorders. It would be easy 
to multiply examples of the influence of these and like causes in the pro- 
duction of disease, and especially to adduce illustrations which might ap- 
pear far more striking than any of the few given above — such, for example, 
as the occurrence in miners and others of special forms of lung-disease, in 
painters of dropped hand, in drinkers of cirrhosis of the liver, delirium 



40 



THE ETIOLOGY OF DISEASE. 



tremens, and so on. But it is obvious that we have here examples, not of 
any mere predisposition which has been gradually acquired, but of the 
direct and specific influence of certain exciting causes to which the sufferers 
have been exposed. 

5. The effects of previous disease in modifying the tendency to subse- 
quent attacks of disease are in many cases very remarkable. In the ex- 
anthemata and allied affections an attack of any one is in a very high degree 
protective against subsequent attacks of the same malady. On the other 
hand, many inflammations tend to repeat themselves. Thus, persons who 
have once had erysipelas of the face generally acquire a liability to at- 
tacks of the same malady throughout the remainder of their lives. So it 
is with rheumatism, pneumonia, bronchitis, tonsilitis, catarrh, renal in- 
flammation, and intermittent hematuria. And, indeed, one of the most 
difficult practical problems with which physicians have to deal is that of 
the counteraction of such acquired tendencies. But there are many dis- 
orders which engender a liability, not to their own recurrence, but to the 
attacks of other diseases. Thus both scarlet fever and gonorrhcea are 
curiously apt to be succeeded by attacks of acute rheumatism. Tubercu- 
losis is generally believed frequently to follow on enteric fever and small- 
pox, and scrofulous enlargement of the cervical glands on mumps. And 
chorea may certainly be regarded as a sequela of both acute rheumatism 
and scarlet fever. To these latter examples may be added the fact, which 
seems beyond dispute, that organs and parts which have been the seats of 
repeated or continuous attacks of inflammation, and have in consequence 
undergone structural changes, and so also pigmentary nsevi, often prove 
the selective sites for the primary development of sarcomatous and other 
kinds of malignant growths. 

It may be convenient to refer here to the special morbid predispositions 
of different organs and tissues. A very little acquaintance with pathology 
is sufficient to prove that the different parts of the system are not all equally 
liable, or liable in proportion to their respective bulks, vascular supply, or 
importance, to the same forms of disease. Thus, each one of the specific 
infectious fevers involves in its progress certain organs, altogether dis- 
proportionately to other organs, if not to the entire exclusion of some ; 
parasites, whether vegetable or animal, limit their attacks more or less 
exclusively to certain parts, such as the skin, muscular system, liver, or 
intestinal canal ; the inflammations of rheumatism and of gout are specially 
wont to seize on the ligaments and other soft parts about joints ; and tu- 
mors, according to their characters, are prone to originate in different 
tissues — tubercle, which is so wide in its distribution, rarety, if ever, ap- 
pearing in the skin, connective tissue, or muscles ; and carcinoma, which 
is even less exclusive than tubercle in its choice of locality, yet preferring 
for its primary manifestation certain organs, such as the uterus, the 
mamma, and particular regions of the alimentary canal. 

6. The influence of heat and cold, of dryness and moisture, and of 
atmospheric impurity in predisposing to disease is universally admitted. 
But here, as in some of the cases previously referred to, we are apt to confound, 
and it is difficult to avoid confounding, their indirect effects as predisposing 
agents with their direct effects as exciting causes. And further, when we 
come to test the relative influences of climates and seasons by their preva- 
lent diseases, our endeavors to arrive at a just conclusion on the subject 



PREDISPOSING CAUSES OF DISEASE. 



41 



are seriously hampered by the coexistence with them (but partly no doubt 
arising out of them) of peculiarities of habit and modes of life, and of 
malaria or other special conditions of unhealthiness. Thus we shall all 
acknowledge the influence of temperature in the production of bronchitis, 
pneumonia, rheumatism, and sunstroke ; but in these cases temperature no 
doubt acts as the exciting cause. Again, we shall all be ready to allow 
that remittent fever, hepatitis, and dysentery are characteristic diseases of 
tropical climates ; but for the first malaria, not temperature, is wholly re- 
sponsible, and the latter two are possibly in some cases also of malarious 
origin. Further, we all know, by personal experience, the ill effects of 
overcrowded close rooms ; and we cannot doubt that deterioration of health 
must result from that constant breathing of vitiated air to which the 
children of the urban poor are generally condemned, and we shall possibly 
rightly attribute much of their early sickliness and prematurity of death 
directly or indirectly to this cause ; but it is certainly difficult accurately 
to identify either the morbid state which it produces directly, or the 
special predispositions to disease which it engenders. 

It is of course beyond dispute that certain diseases prevail exclusively 
or with special severity in certain climates, and that their prevalence varies 
with season, and also with local telluric or hygienic conditions. Thus, 
yellow fever occurs in the West Indies and on the West Coast of Africa 
and some few other localities ; dysentery and hepatic abscess are in a pecu- 
liar degree diseases of tropical India ; Asiatic cholera, dengue, plague, all 
originate, and prevail chiefly or exclusively, in hot climates ; tubercular 
phthisis is one of the especial scourges of the temperate zone. Again, at 
least in our own country, thoracic inflammations are most frequent during 
the cold seasons of the year — acute pneumonia being probably most com- 
mon in the early spring ; diarrhoeal affections prevail in summer ; and 
many other diseases have a tendency, difficult to explain, either to under- 
go exacerbation or to break out, or it may be to subside, at characteristic 
times — thus ague appears chiefly in spring and autumn, and psoriasis and 
some other forms of skin disease have a similar tendency. 

It should be added that (fortunately for us) the human frame is adapted 
to live healthily urfder great varieties of climate, and under great extremes 
of heat and cold ; and that the effects of climate in the production of dis- 
ease are probably less due to simple cold or heat, dryness or moisture, than 
to the neglect, on change of climate, to adapt our habits of life to the 
altered circumstances in which we find ourselves, and to the effects of sud- 
den and unprepared-for variations of temperature. 

7. In close connection with the subject under consideration is the ques- 
tion of variation in the so-called ' epidemic constitution' of different years, 
and in the ' type of disease.' 

By the term epidemic constitution, Sydenham, who first employed it, 
meant a peculiar state of the atmosphere, determined by special telluric 
conditions ; to which, as specific causes, he attributed the development of 
epidemic diseases, such as smallpox, scarlet fever, measles and plague ; and 
by variations in which he explained the epidemic prevalence of one or 
other of these diseases, and a tendency (which he believed to exist) for all 
indifferent diseases occurring during such an epidemic to be modified under 
its influence and to assume some of its characteristics. The advance of 
pathological knowledge since his day has proved that most, if not all epi-. 
demic disorders spread by contagion, and that there is no atmospheric or 



42 



THE ETIOLOGY OP DISEASE. 



telluric influence to which they are due, nor anything beyond actual con- 
tagion which can give, during the presence of Asiatic cholera, or of smallpox 
and the like, any of the special attributes of these diseases to other prevalent 
diseases. Nevertheless, it must be admitted that there is something re- 
markable, and indeed something inexplicable, in the way in which diseases 
— not contagious and miasmatic only, but simply inflammatory also — 
become at irregularly recurring intervals prevalent in a high degree over 
wide areas. In this qualified sense the' expression, " epidemic constitu- 
tion," is still not {infrequently, and may on the whole be conveniently, 
employed. 

By the term change of type in disease is understood, not the transforma- 
tion of one epidemic disease by gradual steps into another disease — a pro- 
cess in which few now believe ; but a change in the quality of diseases, in 
virtue of which they present cycles of greater and lesser intensity of attack 
and of other deviations from the normal standard. Such changes are be- 
lieved to depend partly on variations referrible to the disease itself, partly 
on 4 epidemic constitution,' partly on cyclical changes in the constitution 
of mankind. There can be no doubt that differences of severity and 
fatality do not unfrequently characterize different epidemics of the same 
disease ; and further, it is beyond dispute that, even during the same epi- 
demic, some persons are attacked with much greater or much less severity 
than others, or have the disease in a more or less modified form ; and in 
these senses the fact of variation in the type of disease must be fully ad- 
mitted. There are many, however, who still believe that all diseases have 
undergone a change of type during the last fifty years ; that they were 
formerly sthenic, and were to be cured by blood-letting, whereas they have 
now become asthenic and demand an exactly opposite line of treatment. 
It would be strange if, while the old descriptions of diseases remain accu- 
rately applicable, as in fact they do, to those of the present day, and while 
the health of the population has been undergoing gradual improvement, as 
it has done (if, at least, we may judge by the diminishing death-rates and 
the improved circumstances of the people), the effects of these unchanged 
diseases on the improved constitutions should be to render these latter more 
helpless during their attacks, and more likely to succumb from sheer 
debility. Many will be disposed to admit that the change of type has been 
rather in the medical practitioner than in the disease or in the bodily con- 
stitution, and that the gradual change of treatment has been due, either to 
the slow advance of knowledge with respect to the effects of remedies in 
disease, or to fashion. 

B. Exciting Causes of Disease. 

Amongst the predisposing causes of diseases just passed in review are 
some which act at least as efficiently in the direct production of disease. 
We refer especially to those discussed in paragraphs 4 and 6. It is certain 
that to variations of temperature, combined with changes of hygrometric 
condition of the atmosphere, a very large proportion of local inflamma- 
tions is immediately due. As examples may be cited common catarrh, 
bronchitis, pneumonia, pleurisy, nephritis, rheumatism, inflammation of the 
portio dura causing facial palsy, erysipelas, and various affections of the 
skin. Again, over-indulgence in food, even though the food partaken of 
be fairly wholesome, not only causes sickness and diarrhoea or other forms 
of gastro-intestinal disturbance, but leads ultimately to accumulation of fat, 



EXCITING CAUSES OF DISEASE. 



43 



plethora, indigestion, gout and various disorders arising out of these. So, 
on the other hand, deficiency of sustenance, or deficiency of essential in- 
gredients of that sustenance, induces emaciation, ansemia, debility, dege- 
neration, and various special disorders, the direct production of some of 
which has been demonstrated by experiment on the lower animals, and of 
which scurvy affords a notable example. Not far removed from such 
causes as these are the over-exercise or under-exercise, or abuse of the 
system, or of component parts of it. We need only refer, in proof of their 
efficacy, to the serious consequences which are apt to ensue on sudden and 
very violent muscular efforts, or on long-continued over-exertion of the 
muscular system, to the many injurious effects of sexual excesses, which 
are not entirely due to seminal losses, and to the many nervous disorders 
which originate in overwork of the brain, in prolonged wakefulness, in the 
unconstrained indulgence of the passions, and the like. 

Without meaning thereby to exclude the various causes which have just 
been enumerated from classification among them, we may, with tolerable 
accuracy, group the remaining specific causes of disease under the heads 
of 'mechanical,' 'chemical,' and 'vital;' and we may further divide them 
into the endopathic, or those which originate within the system on which 
they act, and the exopathic, or those which attack the system from 
without. 

1. Mechanical Causes. Exopathic mechanical causes embrace all forms 
of external violence, the results of which fall more particularly within the 
province of the surgeon. Endopathic mechanical causes, on the other 
hand, are of special importance and interest to the physician. They in- 
clude mechanical obstructions of orifices or tubes, whether these obstruc- 
tions be caused by thickening and contraction of their walls, by pressure 
on them from without, or by impacted concretions: such are intestinal 
stricture, hernia, intussusception, and the lodgment of gall-stones, and all 
similar obstructions in the ducts of the liver and pancreas, in the various 
urinary passages, in the larynx, trachea and bronchial tubes, at the cardiac 
orifices, and in bloodvessels. They also include impediments, however 
originating, to the transmission of nerve-currents along the nerves, dila- 
tations of arteries and of other tubes and cavities, perforations or ruptures 
of their parieties, and extravasations or effusions of blood, serum, and other 
matters. It is obvious, therefore, that agencies of this kind are the direct 
causes of a very large proportion of the local diseases to which we are liable. 
But it may be observed that they would probably all have been considered 
by the older writers as proximate rather than exciting causes of disease, 
and that they are in fact in no case the primary causes of the morbid pro- 
cesses from which patients suffer. Thus, the person, who suffers and dies 
from stricture of the oesophagus or bowel, and whose grave symptoms have 
all been referable to the stricture, owes his stricture to previous local in- 
flammatory thickening, or ulceration, or carcinoma; and he who dies from 
the consequences of mechanical impediment to the passage of blood through 
the mitral orifice, traces the affection of the mitral valve to a long ante- 
cedent attack of rheumatic fever. 

2. Chemical causes of disease include all poisonous substances, whether 
they be derived from the inorganic or the organic kingdom, and however 
variously they exert their influence over the system. The great majority 
of these are necessarily exopathic. Some, like the caustic alkalies and 



44 



THE AETIOLOGY OF DISEASE. 



mineral acids, destroy the surface to which they are applied ; others, like 
opium, strychnia, aconite, and snake-poisons, undergo absorption, and 
quickly exert their chief influence on particular organs, or on the general 
system; while others, again, introduced into the organism habitually and 
in minute quantities, slowly induce characteristic organic and other changes, 
and thus what are commonly regarded as definite diseases. Thus, dropped 
hand and colic, or plumbism, are the results of chronic lead-poisoning; 
muscular tremors indicate mercurialism, or the ultimate effect of the inha- 
lation of mercurial vapors ; the fumes of phosphorus after a time cause 
necrosis of the jaws ; the habitual use of ergotized cereals for food is be- 
lieved to bring about a peculiar form of gangrene of the lower extremities; 
and not improbably endemic goitre and cretinism are due to the constant 
slow action of some material agent. We must obviously also include here 
the poisonous effects of certain articles of food — mussels, fungi, sausages, 
and the like — and those which flow from the habitual use of alcohol, tobacco, 
and opium. 

Endopathic chemical causes are principally such as depend on defective 
action of the excretory organs, and the consequent retention in the system 
of effete matters which then act as poisons. The chief emunctories for the 
purification of the blood are the kidneys, liver, lungs, and skin. If the 
kidneys act inefficiently, urea and other excretory constituents of the urine 
accumulate in the blood, and by their presence there at length induce 
epileptiform convulsions, dropsy, anaemia, and other symptoms which col- 
lectively indicate the presence of Bright's disease. If the liver fail to dis- 
charge its normal functions, jaundice follows, and with that, and in some 
degree in consequence of it, many other grave symptoms. When from 
mechanical or other impediment to respiration, the blood becomes over- 
charged with carbonic acid, lividity of surface, delirium, and coma pre- 
sently supervene. The cutaneous exhalation is for the most part merely 
complementary to that of the lungs and kidneys; 'and hence the injurious 
effects of its arrest are not very apparent ; at the same time, doubtless, 
serious consequences are often correctly attributed to its suppression. Here 
we may refer, also, to the ill effects of that accumulation in the blood of 
the various ill-defined products of decomposition, which attends the specific 
febrile disorders, and in a greater or less degree most diseases or patholo- 
gical processes. 

3. Vital Causes We now come to speak of that important class or 

causes to which all contagious or infectious diseases owe their origin — 
causes, which are specific for each specific disease ; which are material ; 
which pass in some way or other from those already affected to those 
who are sound, and implant themselves in their bodies; which grow and 
multiply therein at their expense, causing characteristic symptoms; which 
in a greater or less degree are capable of escaping therefrom, and of then 
similarly infecting a second series of healthy persons, and so on continually ; 
and of which none (so far as we certainly know) has varied intrinsically in 
its effects from the earliest record of its operation up to the present time, 
or upon any part of the earth's surface. It is at once obvious that these 
causes are essentially and utterly different from those mechanical and chem- 
ical causes which have just been discussed. It is impossible to conceive of 
the contagiousness of a strictured bowel, an apoplectic clot, or an attack of 
jaundice; it is contrary to all we know of chemistry, that lead or mercury, 
morphia or the poison of the cobra, or a dose of medicine, should multiply 



EXCITING CAUSES OF DISEASE. 



45 



within the system. But here we have poisons or irritants which do mul- 
tiply in the system, it may be a billion-fold, every unit of whose product 
is as efficient in imparting disease as was the unit from which it sprung. 
These facts seem quite incompatible with any other view of the nature of 
these causes than that they are actual living things. 

That some of them are living is absolutely certain ; we mean 'parasitic 
animals and vegetables. Of animal parasites, some live and swarm on the 
skin, or in it, and readily transfer themselves from one body to another; 
some live in the alimentary canal or in the solid organs, and these, though 
still capable of infecting other healthy persons, infect them indirectly only 
and after undergoing remarkable transformations external to the body of 
their host, and often in the organism of some lower animal. Superficial 
diseases due to the presence of vegetable parasites also are highly contagious. 

With regard to the contagia, properly so called, namely, the infectious 
matters to which the several exanthematous and other similarly infectious 
fevers are due, there is far less direct evidence in favor of their being living 
things. Nevertheless some such evidence, to the effect that they consist 
in marvellously minute particles of living matter or protoplasm, has been 
adduced, and will at a subsequent page be more fully considered. 

The poison or malaria on which ague and remittent fever depend, al- 
though not communicable from man to man, has a certain resemblance to 
the contagia, both in its mode of infecting the system, and in the effects 
which mark its operation there, and hence not improbably is of a like 
nature with them. 

It seems convenient to advert here to the fact that many inflammations, 
originating apparently in indifferent causes, either are inherently infec- 
tious or acquire under particular circumstances an infective character, and 
that they spread, like the diseases which have just been considered, in 
some cases by direct contact or inoculation, in others, by atmospheric car- 
riage. Thus, most practical medical men will readily admit the communi- 
cability of common catarrh and of tonsillitis, the contagiousness under 
special conditions of even idiopathic erysipelas, and the readiness with 
which catarrhal ophthalmia and impetigo occasionally spread. Gonor- 
rhoea furnishes a yet more striking example of the same fact. These cases 
are important, because they seem to show the possibility of the spontaneous 
development of contagious elements within the system. It is probable 
that here the contagious property resides in the pus- or exudation-corpus- 
cles whose development attends the inflammatory process. It must be added, 
however, — that a very large number of diseases, fundamentally distinct 
from one another, are yet linked together by the common bond of the 
occurrence in them of inflammation as a more or less prominent feature ; 
that one tendency of advancing pathological knowledge is to recognize that 
in a larger and larger number of so-called 'inflammations,' the inflamma- 
tion is not the essential element in the disease, but merely one out of a group 
of several morbid phenomena, all starting from the direct influence of some 
specific cause : and that hence it may, perhaps, eventually be discovered, 
that all of these catching inflammations are, in the same sense as scarlet 
fever or mumps, specific diseases dependent on specific causes. 

The causes of carcinoma and other varieties of malignant disease, and 
indeed of proliferating tumors generally, are very obscure. It is not diffi- 
cult to undeistand, that when once a tumor, destined to be malignant, has 
made its appearance in any part, the subsequent development of secondary 
tumors in the neighboring lymphatic glands, and in remote organs, may 



46 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



be due to the conveyance thither from the primary growth of prolific par- 
ticles of its specific protoplasm; and that, hence, the diffusion of such 
tumors throughout the organism may, like the diffusion of smallpox 
throughout a population, be due to a contagium — but to a contagium, in 
this case (as probably also in certain inflammations) originating in the 
living tissues. But this explanation throws no light on the primary causa- 
tion of such growths, and of their specific distinctions from one another. 
They seem, at any rate frequently, to be induced by the long-continued 
local operation of non-specific causes of irritation ; and their specific char- 
acters, which are perhaps less absolute than they seem to be, may depend 
in some degree on the nature of the tissue which becomes irritated into 
overgrowth. 



III. PHYSIOLOGICAL PROCESSES IN HEALTH. 

The processes of disease, however widely they may seem to diverge from 
those of health, are merely modifications of them, and their types must be 
sought in the normal physiological processes by which the body is devel- 
oped, grows, maintains itself, and finally dies. It will be well, therefore, 
before considering them in detail, to pass briefly in review the physiologi- 
cal processes out of which they arise. 

A. It is now admitted by physiologists, with almost perfect unanimity, 
that the first origin of every living thing, as also every living particle of 
the developed organism, is a viscid, homogeneous, colorless, albuminous 
substance, known as protoplasm or germinal matter ; and that this is en- 
dowed with remarkable powers, in virtue of which, under appropriate 
conditions of warmth, moisture, and the like, it is capable — first, of throw- 
ing out processes or otherwise altering its form, and thus, on the one hand, 
of investing and absorbing solid particles, and, on the other hand, of actual 
locomotion : second, of growing, and maintaining itself, by imbibing and 
appropriating the nutritious matters which surround it, while discharging 
whatever is superfluous or excrementitious or effete : third, of multiplying 
by fission or by gemmation : and last (in dependence on its immediate 
parentage and other conditions), of undergoing further development or 
differentiation, so as to take part in the formation of organs, or itself to 
become an organ performing special functions. 

Quiescent protoplasm generally occurs in the form of small round or 
oval masses, often presenting an embedded nucleus, or several such bodies, 
and under many circumstances a thin membranous investment, and hence 
that combination of characters which we recognize in the typical nucleated 
cell. The earliest stages in the development of the embryo, and the 
earliest stages in the development of" organs, are characterized by the 
abundant formation of cells of this kind (without, however, the investing 
membrane), which are hence termed embryonic cells. These bodies stand, 
therefore, at the bottom of all growth and all development ; and it is by 
their multiplication and by the changes which they effect, or undergo, that 
the complex organism of the body is gradually evolved and finally per- 
fected. Thus, in the area germinativa the embryonic cells arrange them- 
selves in three layers — the uppermost or serous, the undermost or mucous, 
and an intermediate layer ; and, by a process of development or differen- 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



47 



tiation, from the cells of the uppermost layer are gradually produced the 
central nervous system and the epidermis Avith its appendages : from those 
of the lowest layer, the epithelial lining of the alimentary canal and of the 
various glandular organs which communicate with it : and from those of 
the intermediate layer, the vascular system with the ductless glands, and 
the muscular, osseous, and connective tissues. 

B. The result of the processes here adverted to is the formation of a 
series of simple tissues, which group themselves here and there into com- 
plex specialized masses, named organs. These tissues may be arranged, 
according to Virchow, in three categories, the ' epithelial,' the ' connec- 
tive,' and those of a higher grade. 

1. The tissues belonging to the Jirst category — the epithelial — are evolved 
mainly from the serous and mucous embryonic layers, and comprise — the 
epidermis, with the hair, nails, and sebaceous and sudoriparous glands ; 
the epithelial lining of the gastro-intestinal mucous membrane, with that 
of the hepatic ducts and other glandular organs connected with that mem- 
brane ; the genito-urinary and pulmonary epithelia ; and the endothelia of 
the serous and synovial cavities of the body, of the bloodvessels and lym- 
phatics. In all these cases, or in nearly all of them, the tissue is composed 
of typical nucleated cells — that is, of masses of protoplasm containing 
nuclei and invested in membrane — so arranged as to be in exact contact with 
one another. Minor differences, yet of great practical importance, are 
observed between the cells of different epithelia ; thus, they vary largely 
in size and form, and in the thickness and other special characters of their 
membranous investment. In the case of the outer layers of the epidermis 
and hairs, nuclei and protoplasm wholly disappear, and each cell becomes 
a mere lifeless horny flake. The functions of epithelia are very various : 
some, as those of the skin and bloodvessels, are merely protective ; others, 
such as that of the mucous surface of the alimentary canal, absorb ; while 
those of glandular organs either manufacture and secrete products service- 
able to the economy, or separate from the blood, and excrete matters which 
are effete or injurious. 

2. The tissues of the second category — the connective — are developed 
almost exclusively from the intermediate embryonic layer, and pervade all 
parts of the body, with the exception of the epithelia, forming a kind of 
network, in the interstices of which the higher tissues and the elements of 
organs are contained. They consist of nucleated masses of protoplasm, 
which are often exceedingly minute, always surrounded by a wall of greater 
or less thickness, and either rounded and isolated from one another, or 
stellate and furnished with processes communicating with those of neigh- 
boring cells. The essential morphological distinction between epithelium 
and connective tissue is, that in the former the cells are in absolute con- 
tact, in the latter they are separated from one another in a greater or less 
degree by some intervening substance — either an unorganized or lifeless 
deposit, or portions of the higher living tissues. According to the nature 
and amount of this intervening substance, or to peculiarities presented by 
the cells, connective tissues may be divided into several varieties. In 
ordinary connective tissue, as also in fasciae and tendons, the protoplasm 
is scanty and stellate ; and the intervals, which are large, are occupied by 
wavy bands of white fibrous tissue and more or less yellow elastic fibre, 
both of which are either simple secretions from the living protoplasmic 
masses, or the mummies of defunct cells. This variety of connective 



48 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



tissue yields gelatine. In common cartilages, the cells are round or oval, 
and separated from one another by a dense homogeneous elastic substance, 
which appears to be formed by the progressive thickening of the cell-walls 
and by their coalescence, and yields chondrine. In bone, the lacunae and 
canaliculi mark the position of the cells and their radiating processess, the 
proper constituents of the bone occupying the spaces which these include. 
The central nervous organs and the lymphatic glands possess a peculiar 
form of connective tissue, termed 1 retiform,' in which the essential ele- 
ments of these organs represent the separating material, and in which the 
proper cellular elements of the connective tissue are minute and stellate, 
and the rays passing between them are delicate and homogeneous, and 
inclose exceedingly small spaces. Mucous connective tissue, which is 
abundant in the developing fetus, is represented at birth by the tissue of the 
umbilical cord, and throughout the remainder of life only by the vitreous 
humor of the eye. In this the intermediate substance is fluid — mucus in 
fact — and contains mucine. Lastly, passing by some unimportant modi- 
fications of connective tissue, it may be pointed out that, in the choroid, 
spinal pia mater, and elsewhere, the proper cells of this tissue contain pig- 
ment, and that in many regions they are distended with oil. In the former 
cases, we have pigmental tissue ; in the latter, fat. 

It is upon the essential elements of the connective tissue — namely the 
protoplasmic particles, or cells, and the processes springing from them, 
which, with certain modifications of character, are distributed nearly uni- 
versally throughout the organism — that, according to Virchow, the action, 
growth, and maintenance of the organism immediately depend ; and just 
as (to take bone for an illustration) we find certain districts or territories 
(the Haversian systems) under the nutritive governance of particular blood- 
vessels, so we find still smaller territories within them (the lacunar systems) 
over the welfare of each of which a single cell appears to preside. The 
latter are termed by Virchow ' cell-districts.' 

3. The third category of tissues comprises mostly those which are tubular, 
and formed either by the juxtaposition and coalescence of cells, or of cells, 
or protoplasm, which have in some other manner undergone a high degree of 
specialization. Among them we may name nerve-ceils, and nerves, striped 
and unstriped muscular fibres, capillary vessels and lymphatics. 

4. Lastly, conqjlex organs, such as muscles, bones, glands, brain, and 
the like, are formed by the association, in various degrees of complexity, 
of several of the above-enumerated tissues. 

Thus, the organism may be regarded as a combination of vital and non- 
vital elements : — the latter comprising various more or less complex chemical 
compounds, which have been prepared and deposited through the agency 
of the living matter, and whose subsequent changes and duration are regu- 
lated by the action of the living elements which are in their immediate 
vicinity ; the vital elements being the protoplasmic masses or nucleated 
cells, which, thickly disseminated, carry on between them all the living 
functions, and form — the universal network of connective-tissue corpuscles : 
those laminated aggregations which constitute the various epithelia, and 
endothelia, and the walls of capillary vessels and lymphatics : the massive 
accumulations which are observed in the central nervous organs, liver, 
lymphatics, and other glands : probably striped muscular fibre, and the 
axis-cylinders and peripheral ends of nerves : and lastly, the corpuscles 
which are free in the circulating fluids. 

It is important to note that the vital properties of protoplasm differ in 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



49 



degree, and in quality, according to its age and the functions to which, by 
process of development, it has become subservient. Thus, embryonic pro- 
toplasm, and its nearest representatives in the mature organism — namely 
leucocytes and connective-tissue corpuscles — especially possess the power 
of multiplication and of differential development ; whereas muscular fibres 
and nerve-cells, which stand at the opposite extremity of the scale, probably 
never, at any rate in health, undergo proliferation or development except 
in their own special groove. 

C. The development, growth, and maintenance, therefore, of the entire 
organism depend essentially on the healthy circumstances, as to nutrition 
and the like, of the protoplasmic elements which constitute its living parts. 
All actively living matter is unstable and short-lived, and needs for the due 
performance of its vital acts (which are always attended with a certain 
amount of waste of tissue) suitable food, which it can imbibe and trans^ 
mute into its own substance, so as at least to supply the place of that 
which was lost. But it needs, also, the removal of the spent nutritious fluids 
in which it is bathed, and of those effete and excrementitious matters which 
it continually emits. 

1. For the purpose of providing a constant supply of nutriment, we have 
the blood, impelled by the heart, slowly coursing through the capillary blood- 
vessels, and ever sweating all save its morphological elements through their 
delicate parietes into the extra-vascular tissues around, and occasionally 
perhaps exuding these morphological elements also ; and for the purpose 
of maintaining a constant removal of the spent pabulum, and of effete 
matters, we have the extra- vascular fluids ever undergoing absorption, 
partly by the agency of the venous radicles, but mainly by the lymphatic 
vessels, which have their origin in the meshes of the capillary network, 
and in the very spaces in which the protoplasmic elements themselves are 
situated. 

2. The nutritious matters of the blood are supplied to it primarily from 
the alimentary canal. Food, after having been triturated and swallowed 
and acted on by the secretions of the various glandular organs which dis- 
charge their contents into the stomach and bowels, is absorbed at the sur- 
face of the mucous membrane — the fluid and more readily diffusible parts 
by the capillary bloodvessels, the fatty and albuminous matters by the 
lymphatics. Those substances which enter by the former route, after 
passing through the liver and perhaps undergoing some change there, 
mingle with the general mass of the blood ; those which enter by the 
lymphatics first traverse the lymphatic glands, carrying thence with them 
the white corpuscles which these glands manufacture, and then like the 
former blend with the circulating fluid. But the surplus nutriment, which 
escapes from the capillary vessels into the tissues external to them, is also 
taken up mainly by lymphatic vessels; and this again, after passing 
through lymphatic glands, and deriving thence morphological elements, 
mingles, like that derived from the alimentary canal, with the blood-stream. 
Lastly the important secretions furnished by the mucous membrane of the 
alimentary canal, and by the viscera which discharge into it, are reabsorbed 
in large proportion with the food, and thus re-enter the circulation. 

3. Effete matters derived from the waste of the organism are dissolved 
in the fluids which are also the carriers of nutritious matter ; and hence 
are removed from the parts in which they are produced by the same 
channels, namely the veins and the lymphatics ; and then mingling with 

4 



50 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



the blood are there further reduced by the reducing agency of the oxygen, 
which it is the function of the lungs to furnish to the blood. Thus, they 
get converted into diffusible compounds of comparatively simple constitu- 
tion, which are then separated from the blood by appropriate emunctories 
— carbonic acid by the lungs, nitrogenous compounds and salts by the 
urine and by the skin, and the coloring matter of the blood by the kidneys 
and the liver. 

4. Presiding over the processes of nutrition, and to a great extent 
regulating them, yet itself entirely dependent upon them for the means of 
its material and functional activity, is the nervous system, comprising the 
central organs, the nerves, and the end-organs of the nerves. By means 
of the nerves every part of the organism, probably almost every protoplas- 
mic mass, is brought directly or indirectly, through the intervention of 
ganglia or of the central organs, into relation with the other elementary 
parts of the organism. Sensations or impressions received at the periphe- 
ral terminations of afferent nerves are conveyed instantaneously either to 
some nerve-ganglion, or to the spinal cord, or to the brain, or to all of 
them; and then, reflected thence along the efferent nerves, certain respon- 
sive influences are transmitted which, according to their destinations, result 
in muscular movement or in glandular action. Thus, the central organs 
are kept informed of what is going on throughout the organism ; and thus 
(to omit all reference to their influence over the voluntary muscles), — by 
acting on the walls of the heart and bloodvessels, they regulate the supply 
of blood to parts, and so control their nutrition and the activity of their 
special functions : by acting on the walls of gland-ducts, they modify the 
rate of escape of the products of the glands : and by means of the trophic 
nerves (which many physiologists now believe to exist), they probably 
exert a direct influence over the action of the essential elements of secreting 
organs. 

D. Ere we bring these preliminary physiological remarks to a conclu- 
sion, a more direct reference must be made than has hitherto been done to 
the fact that decay and death are essential elements in the normal processes 
of life. It has already been pointed out that every act of life is attended 
with waste of tissue, and that living protoplasm is essentially unstable and 
short-lived. It must be added, that every part of the organism has a 
limited duration, which is far shorter than that of the normal duration of 
the body which it contributes to form, and that the parts are removed 
either by slow disintegration and degeneration or are cast off in mass. We 
need only advert, in exemplification, to the shedding of the epidermis and 
of the elements of the excretory glands, to the removal and re-formation 
of bone-tissue, to the generation and destruction of blood-corpuscles, to the 
atrophy of the uterus and the fatty degeneration of its muscular elements 
after parturition, and to the even more complete destruction by similar 
processes of the Wolffian bodies during fcetal life, and of the thymus gland 
during the first few years of extra-uterine existence. Lastly, it must 
never be forgotten, that atrophy and degeneration of organs and tissues are 
normal physiological processes of old age, and that somatic death, in which 
they culminate, is their normal termination. 



MORBID GROWTH. 



51 



IV. PHYSIOLOGICAL PROCESSES IN DISEASE. 

If we carefully consider the intimate processes of disease, we cannot 
fail to recognize the fact, that they consist essentially in nutritive modifi- 
cations of the protoplasmic or vital elements of the tissues — that under the 
influence of abnormal or unwonted stimuli (including the stimulus of ex- 
cessive nourishment), these enlarge, or multiply, or differentiate; that 
when insufficiently stimulated or fed, they undergo atrophy or degenera- 
tion, or perish; and that, as a necessary consequence of such changes, 
their functional attributes become heightened, or impaired, or more or less 
profoundly modified. Thus, on the one hand, we get simple hypertrophy, 
inflammation, or heterologous growth, and, on the other hand, fatty or 
calcareous conversion, or other forms of degeneration; and, again, func- 
tional derangements too numerous to mention, which constitute so large a 
proportion of the symptoms of disease. 

But when we look to the marvellous complexity of the organism, to the 
intimate anatomical relations which subsist between the vascular and the 
nervous and other subordinate systems and organs, and to the correlation 
and mutual dependence of the various functions which all these different 
component parts of the organism are called upon to perform ; and consider 
that the healthy structure and function of each is involved in a greater or 
less degree in the similar integrity of every other ; we must admit (what 
the slightest practical experience will confirm), that we cannot limit our 
view of morbid processes to these intimate changes alone, but must embrace 
within it the structural and other modifications of organs to which such 
changes give rise, as well as those further nutritive and functional disturb- 
ances which, in a variety of ways (mechanical, chemical, and other), dis- 
ease of one part necessarily evokes in a greater or less degree in all other 
parts of the system. We proceed to discuss at length the several matters 
here adverted to. 

A. Morbid Growth. 

1. General Observations. 

a. Growth and development of cells Whenever the protoplasmic parti- 
cles or cell-elements of a part are stimulated to unwonted growth, they 
first increase in bulk, and become turbid, or minutely and indistinctly 
granular, and if stellate, fusiform, or caudate, at the same time retract 
their processes, and asume a more uniformly rounded shape ; and then, by 
internal gemmation or fission, each cell gives origin to two or more smaller 
cells, which in their turn repeat more or less accurately the processes of 
growth and proliferation. The results of such stimulation, so far as regards 
the cells themselves, are, that sometimes the newly-generated cells acquire 
in all respects the same characters as had formerly belonged to their imme- 
diate ancestors, that sometimes they retain permanently the immature or 
embryonic condition which represents the early or indifferent stage of 
nearly all cell-growth, and that sometimes again they undergo development 
into cellular bodies which differ materially in size, form, and attributes, 
from those which gave them origin. Simple hypertrophy or hyperplasia 
furnishes an example of the first of these alternatives, inflammatory cell- 
production of the second, and heterologous tumors of the last. 



52 



MORBID GROWTH. 



b. Conditions associated with over-growth. — But where there is exag- 
geration of cell-growth, there necessarily is also at least proportionate 
exaggeration of the various conditions which are subsidiary to such growth 
— namely, exaggerated afflux of blood, exaggerated accumulation of nu- 
trient fluid, exaggerated molecular destruction, and exaggerated efflux of 
superabundant and effete materials. 

Increased afflux of blood is determined mainly by reflex dilatation of 
the arteries, capillaries, and veins, which minister to the needs of the 
atfected part, and in a subordinate degree by increased force and frequency 
of the heart's contractions, and produces one form of what is known as 
' congestion.' 

Increased accumulation of nutrient fluid in the extravascular tissues 
is due to the preternaturally abundant escape of it from the dilated capil- 
laries — an escape doubtless dependent in some degree on the vital influence 
exerted by the protoplasm of the capillary walls, and by the over-growing 
protoplasm external to them. The tissues consequently get swollen, soft, 
and juicy, and in a greater or less degree £ dropsical.' 

All vital activity, whether this manifests itself by material changes or 
by functional excitement, is attended with molecular disintegration, which 
has some exact quantitative relation with it ; and hence increased vehe- 
mence of growth, and of reproduction, is necessarily accompanied with a 
proportionately increased production of effete and excrementitious matters. 
But, in addition, undue rapidity of cell-growth and development always 
involves a corresponding tendency to fall into premature decay and disso- 
lution : and hence arise fatty and other forms of degeneration, the products 
of which accumulate, and mingle with those of molecular disintegration. 
It is thus that the fluids of the affected region tend to become surcharged 
with innutritious, waste, and often noxious materials. 

The increased absorption which takes place is probably dependent, in 
some measure, on the more active passage of fluid by endosmosis through 
the wall of the venous radicles, but is certainly due mainly to the more 
direct action of the lymphatic vessels. Indeed, it is almost impossible to 
suppose that those slightly diffusible substances, albumen and fibrinogen, 
should, in the face of the opposing pressure from within the bloodvessels, 
be capable of re-entering them, or that solid particles, whether indifferent 
or specialized, should be removable by any other route than that furnished 
by the open mouths of the lymphatics. And that these really are the 
main agents in the removal of probably everything, save a variable pro- 
portion of water and dissolved salts, is shown by the tendency which, 
when largely over-worked, they and the glands in their course have to 
become enlarged and presently inflamed, or involved in the identical pro- 
cesses going on at the seat of absorption. 

c. Migration of leucocytes — One of the most interesting phenomena, 
connected with the subject of local proliferation, is the fact, stated many 
years ago by Dr. Addison, and since then clearly established by the experi- 
ments of Cohnheim and the later observations of many other physiologists, 
that in artificially produced irritation or inflammation of the tissues of the 
frog, after retardation of the current of blood in the vessels of the part has 
taken place, the white corpuscles gradually penetrate the vascular walls, 
and presently pass completely through into the tissues external to them. 
It has further been shown that these emigrant corpuscles take an active 
personal part in the proliferation which ensues ; that is to say, that they 
.then, as welhas the proper protoplasmic masses of the part, give origin by 



LOCAL SPREAD 



GENERALIZATION. 



53 



gemmation or fission to new generations of cells. How far this process 
contributes to inflammatory proliferation in warm-blooded animals, or may 
be regarded as an essential element in the development of non-inflamma- 
tory growths, is at present in great measure a matter of inference. Still 
there are many good grounds for regarding it as an important item in all 
cases of abnormal cell-proliferations. And it is far from unlikely that it 
may be equally importantly concerned in the normal processes of growth 
and development. 

d. Tendency of morbid growth to spread locally — Morbid cell-develop- 
ment, occurring primarily at any one spot, generally has a tendency to 
spread in the neighborhood of that spot. The direction of local spread is 
in most cases largely determined by the structure and connections of the 
tissue or organ in which the growth has originated. Thus, growths be- 
ginning in the cutis or mucous membrane are prone to limit their exten- 
sion to these structures ; and the same rule applies to the kidney, ovary, 
and other organs. Nevertheless, in many cases the morbid process tends 
gradually to involve all adjoining parts. This local spread is sometimes 
effected by the progressive involvement of the healthy tissues immediately 
surrounding the focus of disease ; and very often partly by this process, 
but partly also by the appearance of new foci of disease in the vicinity of 
the primary focus, and by their gradual coalescence with it and with one 
another. It is sometimes determined by the lines of capillary lymphatics 
and bloodvessels. 

e. Tendency of morbid growth to become generalized. — The tendency 
to the simultaneous or consecutive occurrence of the same kind of morbid 
proliferation in dilferent, and even remote, parts of the organism is trace- 
able to a variety of causes, presents obvious and characteristic differences, 
and has therefore a widely different significance in different cases. The 
matter is one which deserves, and indeed demands, consideration ; and we 
proceed, therefore, to discuss it in some detail. A person,, in apparently 
the best of health, finds that he has a fibrous or fatty tumor in the subcu- 
taneous connective tissue, or an osseous or cartilaginous tumor growing 
from the shaft of some bone ; and probably in a short time it is ascertained 
that many other tumors, identical in character with the one first detected, 
are making their appearance in the connective tissue or the bones (as the 
case may be) of different parts of the body. Now it is indubitable that 
we have here a curious tendency in certain tissues of the body to undergo 
special morbid changes. To what is this tendency due ? The first-formed 
tumor may be distinctly traceable to some local injury ; has the growth 
which resulted from that injury so infected the system as to have led to 
the multiple development of similar growths throughout the same tissue 
as that which was primarily involved? Or have all the tumors (including 
the first) resulted from the common operation of some independent morbid 
irritant or poison diffused generally throughout the system ? Or is there 
some inherent weakness or vice in the particular tissue, which has become 
thus largely affected, rendering it liable to take on specific morbid pro- 
liferation under the influence of mechanical violence or any other indif- 
ferent cause? In the examples which have been adduced (and many 
similar ones might be added), the last of the three suggested explanations 
will doubtless be regarded as the only tenable one ; and probably it is the 
correct one. At all events, we have no grounds for assuming — from the 
presence of cachexia or other associated abnormal conditions, that any 
poisonous matter either is or has been present in the system ; or, from the 



54 



MORBID GROWTH. 



presence of lymphatic implication, that the primary seat of disease was 
the source of infection. 

The case, however, is not quite so simple as it appears to be at first 
sight. The skin, like the bones or connective tissue, constitutes a special 
constituent of the organism, and like them (though in a still higher de- 
gree) is liable to many morbid conditions which are peculiar to itself, and 
which may be distributed at intervals over its surface. Now a patient 
may have psoriasis, beginning perhaps in a patch on the elbow or knee, 
and diffusing itself in spots over the greater part of the body. His father 
may have suffered from the same disease, and his brothers and sisters also 
may be subject to it. The case is one of hereditary predisposition. Now, 
probably no one would dream of suggesting that the spread of the disease 
was due here to the infecting influence of the patch which first appeared 
on the knee or elbow ; and certainly no direct evidence could be adduced 
in favor of its dependence on any morbid irritant carried by the blood. 
The case would doubtless be regarded as equivalent, in point of origin, to 
that of multiple fibrous tumors or exostoses. But another patient has 
psoriasis, differing a little in details of distribution and color, but (unless 
we go into the previous history and subsequent progress of the case) prob- 
ably in no other respect from that observed in the former patient ; and 
further, at the time of observation he may in every other sense be perfectly 
healthy. He had a chancre, however, some time previously, and his skin- 
disease is due to the syphilitic poison. Or, to take another example — an 
apparently healthy person becomes liable, without obvious cause, to urti- 
caria, and suffers from it off and on for years, perhaps for the remainder 
of his life. It is little, if at all, influenced by diet or habits and altogether 
uncontrollable by medicinal treatment, and moreover may be readily in- 
duced by a pinch or scratch. There seems no reason to regard this, any 
more than simple psoriasis, as the result of a specific irritant working from 
within. But another person takes a meal of mussels, and presently pre- 
sents, together with more or less violent constitutional disturbance, an 
abundant urticarial eruption. Now here the relation between cause and 
effect is as obvious as in the case of syphilitic psoriasis. We have, thus, 
clear evidence that both psoriasis and urticaria are producible by the local 
operation of special poisons, which have been introduced from without, 
and have infected the system, and that the former may appear without 
necessary contemporaneous manifestation of other symptoms of disease. 
But do not these facts throw doubt on the non-specific origin of so-called 
' idiopathic' psoriasis and urticaria, and hence also on the assumed non- 
specific causes of fibroma, exostosis, and the like ? 

Nevertheless, while many specific affections of particular tissues are 
certainly traceable to the influence of specific irritants, it seems not im- 
probable that other such affections are due simply to the influence of indif- 
ferent causes acting on parts which have acquired special aptitude to take 
on such morbid action. At the same time it must be admitted, that the 
absence of collateral evidence of the presence of systemic poisoning by no 
means proves the absence of such poisoning; and, further, that the apparent 
commencement of the above or any like lesions from injury does not make 
it certain that this injury was its essential cause. 

The difficulties which have just been briefly considered are equally 
apparent in the case of carcinoma and other infecting tumors. These, like 
exostoses and fibromata, become multiplied throughout the organism, and 
like them repeat in each newly-formed growth the characteristics of the 



CERTAIN TISSUES OR ORGANS. 



55 



growth which was first developed. But they differ from them essentially 
in being heterologous in structure from the tissues wherein they first make 
their appearance, and in the fact that they are not, or not so obviously, 
limited in their further distribution to one special form of tissue. They 
differ from them also in the fact that, however we may explain their origin, 
the first-formed mass inoculates the system with the disease, as truly as 
the inserted variolous contagium inoculates a person with smallpox, and 
exactly in the same way as a chancre infects its subject with constitutional 
syphilis. Thus, if a carcinomatous tumor makes its appearance in the 
testicle, the patient for a time seems, and probably is, free from disease 
elsewhere; but presently other organs get implicated, and in a certain 
sequence. First, the lymphatic glands, into which the testicular lymph- 
atics run, become involved — these are the lumbar glands; and then, after 
an interval, the disease appears simultaneously in many tissues and organs. 
If a patient has carcinoma of the glans penis, the next manifestation of 
the disease occurs exactly where the effects of syphilis first reveal them- 
selves, subsequently to a chancre of the same part — namely, in the inguinal 
glands. And in this case, again, at a later period the disease becomes 
generalized. The same rule applies equally to cancer of breast, uterus, or 
pylorus, and indeed to any primary cancer no matter what its seat: first, 
the lymphatic glands in the neighborhood, and especially those which lie 
in the direct route between the tumor and the thoracic duct, suffer ; and, 
later on, patches of carcinoma appear, distributed throughout the organism. 
It must be added that, in diseases of this kind, every secondary tumor is 
equally infective with that which was first developed; and consequently 
that, just as the primary tumor causes disease in the lymphatic glands 
related by position to its seat, so each secondary tumor tends sooner or 
later to infect those lymphatic glands which are in immediate connection 
with it. 

f. Tendency of certain morbid growths to limit their distribution to 

certain tissues or organs But although carcinomatous tumors, and such 

growths as are related to them by their mode of dissemination from a pri- 
mary focus of disease, undoubtedly tend, when they become generalized, 
to involve a much wider range of tissues and organs than do fatty tumors, 
exostoses, and the like, it is nevertheless certain that they have preferences 
or elective affinities, and that these are in some degree characteristic for 
each species of tumor; and further that, as Virchow distinctly points out, 
the parts in which such affections usually originate are especially the parts 
which their secondary manifestations seem to avoid, and conversely. Thus 
tubercle and carcinoma, although severally disposed to involve secondarily 
a large number of organs, and many of them in common, present obvious 
peculiarities of distribution ; for while both of them are specially apt to 
attack the lungs, brain, and serous membranes, carcinoma is yet more 
disposed to attack the liver, which tubercle generally avoids, and tubercle 
has a marked affinity for the mucous membrane of the bowels and for the 
spleen, in both of which situations secondary cancer is certainly rare. 
And thus, again, while primary carcinoma is common in the breast, womb, 
and alimentary canal, these parts rarely get involved when carcinoma 
originates in some other part of the system. The cause of the apparent 
capriciousness of distribution of secondary growths is very obscure. It is 
of course easy to understand why the lungs, which form a kind of filter to 
the universal blood, should be peculiarly liable to them ; and why organs, 
such as the liver and kidneys, which receive a specially copious supply of 



56 



MORBID GROWTH. 



blood or have such arrangements of vessels as retard or lengthen its passage 
through them, should be affected more frequently than others. But neither 
such conditions, nor others connected with the relative functional activity 
of organs, influential, though they be, are alone sufficient to explain the 
phenomenon. It has recently been ascertained that lymphatic tissue is 
very abundantly distributed throughout the organism ; and there is some 
reason to believe, that the generalization of both tubercle and lympho- 
sarcoma is connected with this fact, and depends either on some special 
proclivity to morbid processes which this tissue acquires under certain 
constitutional conditions, or else on the circumstance that it is the appro- 
priate soil for the germination of the seeds of lympho-sarcoma and of 
tubercle. The latter is probably the correct explanation; and indeed, 
probably also in other cases, apparent capriciousness is mainly dependent 
on the special suitability of different tissues and organs for the reception 
and growth of different specific morbid elements — an explanation which is 
in entire accordance with all we know of the behavior, of the contagia of 
the exanthemata, of animal and vegetable parasites, and indeed of other 
organic and inorganic poisons admitted into the organism. 

g. Connection of dyscrasia with the origin of morbid growths Nothing 

which has yet been said relates in any degree to the question of the pri- 
mary origin of infecting growths; it has simply been shown that when 
once developed they become sources of specific infection to their unfortu- 
nate possessors. This primary origin is referred by many persons to a 
' dyscrasia' or morbid condition of system, itself supposed to be produced 
by the presence of some morbific matter or influence residing in the blood ; 
and indeed Mr. Simon, who formerly adopted this view, regarded a carci- 
nomatous tumor as a newly-developed organ, whose express purpose was 
to effect the separation of such poison from the organism. There are 
several considerations which lend countenance to this hypothesis : — when 
a person exposed to atmospheric changes contracts pneumonia or any other 
variety of internal inflammation, an interval elapses between his exposure 
and the commencement of the inflammation, during whicli some abnormal 
condition of the system — a dyscrasia — is present ; so again the incubative 
stage of smallpox or measles is a period of specific dyscrasia ; and further, 
at any rate as regards tuberculosis, we know that it is apt to come on in 
individuals who have fallen into general ill-health. But, on the other 
hand, these examples are none of them strictly analogous to that of carci- 
noma; and one indeed (that of the exanthem) fairly considered tells the 
opposite way — for its incubative period corresponds, not to the supposed 
incubative stage of carcinoma, but to the period which elapses between the 
first appearance of a tumor and its generalization. Besides, in the great 
majority of cases in which we have the opportunity of observing the first 
manifestations of carcinoma, these are certainly not preceded by any evi- 
dence of ill-health ; and, moreover, no such evidence becomes apparent 
until the patient is obviously beginning to suffer, directly or indirectly, 
from the effects of his disease. 

The existence, then, of initial carcinomatous and other such specific dys- 
crasiae may fairly be denied — at all events, the only proof of their existence 
is the appearance of those very lesions which are attributed to their influ- 
ence. And hence the only sense, in which such a dyscrasia can be con- 
ceded, is the sense in which we should admit a preliminary dyscrasia as 
the source of enchondromata, exostoses, fibrous tumors, leprous patches, 
and the like — a dyscrasia, that is to say, of limited distribution, and con- 



\ 

DYSCRASIA. 



51 



sisting simply in a tendency (congenital or acquired) in certain parts of 
the body to undergo a special kind of proliferation under the operation of 
various forms of irritation. It need not of course be denied in this case, 
any more than in that of non-infective growths, that such a tendency may 
exist simultaneously in various parts of the body ; and that hence, although 
it is certainly not the rule, there may be a concurrent primary outbreak of 
infective growths in two or more localities. 

h. Secondary dyscrasia. — But although a state of cachexia, or a dys- 
crasia, is not an essential antecedent of primary infective growths, there is 
no doubt that a condition of cachexia speedily follows upon their appear- 
ance. The fact has already been adverted to that, from any focus of mor- 
bid proliferation, there is an abnormally large reflux of nutrient fluid into 
the general circulation, partly by the veins directly, but chiefly by the 
lymphatics, and that this nutrient excess is largely charged with effete and 
morbid products, generated in the diseased area. These products com- 
prise — the ordinary waste-materials, such as carbonic acid, and urea; 
materials which are traceable to the special chemical constituents of the 
part involved, earthy matter if it be bone, phosphates if it be brain ; and 
probably also fibrine or fibrine-producing substance, which, as Virchow 
suggests, is manufactured at the seat of disease, and being removed thence 
by the lymphatics overcharges the blood and gives it its inflammatory cha- 
racter. But, in addition, specific affections yield specific elements, which 
also traverse the lymphatics, and presently mingle with the blood. What 
these are is not accurately known ; but probably (judging from the analo- 
gies afforded by the infectious fevers) they are living protoplasmic particles 
evolved by the primary growing mass, which get arrested in the lymphatic 
glands and then infect them, by either growing parasitically among their 
elements, or (sperm-like) imparting to them specific properties, and which 
presently are shed thence in new generations, through the thoracic duct 
into the blood-stream, to sow themselves in distant organs. Now, in all 
these processes, it is obvious that we have ample sources of deterioration 
of the general health, and of functional disturbance of various parts of the 
organism — in other words, of a secondary dyscrasia. But it is obvious, 
also, that the degree and character of the dyscrasia will vary according to 
the peculiarities of the morbid process to which it is due, and especially 
that that accompanying the development of infective growths will be 
attended with specific characteristics. Further, more or less in most cases, 
but in the last more particularly, dyscrasia will probably be largely in- 
creased, by the constant drain of nutriment which the growth and ulcera- 
tion of tumors necessarily involve, and by the obstacles which, by pressure 
or otherwise, these so often interpose to the due performance of important 
or necessary functions. 

When secondary dyscrasiae are present we often find that some mechani- 
cal injury, or the result of some such injury, attracts, as it were, specific 
morbid processes. When, for example, a patient is suffering from consti- 
tutional syphilis, a local outbreak is often thus determined. It is probable 
that this phenomenon is due to the fact that parts, in which certain non- 
specific morbid processes are in progress, furnish a specially suitable soil 
for the growth and development of specific elements of disease, which 
happened to be circulating in the blood. The interesting experiments of 
Chauveau seem strongly to confirm this view. He found that, on inject- 
ing putrid fluids containing bacteria into the blood of healthy animals, no 
special consequences beyond some constitutional disturbance necessarily 



58 



HYPERTROPHY. 



followed ; but that if, after injecting them, the operation of twisting, and 
thus strangulating, one testicle was performed (an operation common in 
France and leading to the gradual wasting of the organ) violent inflamma- 
tion with sloughing, probably attributable to an abundant development of 
bacteria, took place in the injured part, the opposite uninjured testicle 
remaining altogether unaffected. 

i. Meaning of terms malignant and innocent. — It may be well here 
briefly to explain the meaning of the terms 'innocent' and 'malignant,' 
as applied to morbid growths. Malignant is almost synonymous with in- 
fecting ; but not quite — for a chancre and an inoculated variolous pustule 
are both infecting growths, yet not malignant. The word implies, there- 
fore, something more than is presented by either of these affections. It 
implies in fact, additionally, that the morbid process going on in any one 
locality has a tendency to invade all the tissues which are about it, and 
none whatever towards cure, or even to remain quiescent. A malignant 
tumor may, therefore, be defined as one which tends to involve all sur- 
rounding structures, and to disseminate itself through the agency of the 
lymphatics and veins, and has no disposition to spontaneous cure. The 
term ' innocent' is mostly understood to signify simply that a tumor is 
non-infective. Malignant tumors often present other characters which, 
though not necessarily associated with malignancy, are yet highly sugges- 
tive ; these are, aptitude to recur after removal, abundance and rapidity of 
cell-growth, softness and juiciness of tissue (the juice being milky), great 
vascularity, and marked differences of texture as compared with that of 
the parts in which they originate. 

A very characteristic feature of most morbid proliferations, whether 
they be malignant or innocent, is their quasi-parasitic nature — their dis- 
position to grow and to maintain themselves, independently of the general 
health of the body in which they are developed, and from which they 
derive their sustenance. Thus, a large abscess, so far from becoming 
starved by the gradual emaciation of its possessor, will often go on increas- 
ing even more rapidly as his body dwindles away. And so also, enchon- 
dromatous, fatty, and carcinomatous tumors, and tubercle, show no signs of 
impaired vigor of growth, even while the patient is progressively wasting 
under their influence. Over-nutrition and under-nutrition of the body of 
their host are alike without obvious influence over their progress. 

2. Hypertrophy. Hyperplasia. 

The term 'hypertrophy' is commonly used loosely of all organs or 
tissues which, from no matter what cause, have undergone abnormal in- 
crease of bulk. Thus, a liver enlarged by fatty deposit or lardaceous 
infiltration is often said to be hypertrophied, as also is an ordinary swelled 
testicle, or a lymphatic gland affected with tubercle or carcinoma. But in 
such cases as these, the enlargement is due essentially to the deposit of 
some extraneous matter, or the development of some inflammatory or 
other morbid growth ; and the normal structure of the organ, so far from 
being increased in quantity or size, has probably undergone atrophy or 
degeneration. 

True hypertrophy of an organ consists, either in an enlargement of its 
essential elements, or in an increase in their number. By Virchow the 
latter variety of over-growth has been distinguished as ' hyperplasia.' 
The former process is exemplified by the enormous enlargement of the 



INFLAMMATION. 



59 



unstriped muscular fibres of the womb which takes place during the pro- 
gress of pregnancy ; the latter by the over-growth of bone, which is effected 
simply by the multiplication of its elementary parts. It is very difficult, 
however, in many cases to determine positively by which of these two 
processes an over-grown organ has become enlarged ; and doubtless they 
frequently co.-operate. 

Of all morbid processes, simple hypertrophy is that which seems to 
approach nearest to the processes of health ; indeed it is mostly due to the 
operation of the very causes which produce normal increase of bulk, and 
in a very large number of cases is, for a time at least, protective or other- 
wise beneficial. Hence, it is difficult to draw the line between that normal 
growth of the heart, which comes with advancing years and activity of 
body, and that excess of enlargement which sustained and over-violent 
exertion brings about, and which presently reacts injuriously. Again, 
how much more speedily would obstructive disease at the cardiac orifices 
prove fatal, if hypertrophy of the heart's walls did not naturally follow 
upon their efforts to overcome that obstruction. Similar morbid hypertro- 
phies of the muscular parietes of hollow viscera are always apt to arise 
under circumstances which compel them to long-continued unwonted 
action. We may refer to the hypertrophy of the stomach which occurs 
when the pylorus is diseased, to that of the intestine in cases of intestinal 
obstruction, and to that of the bladder, or ureter, or other ducts when 
mechanical impediments prevent the due escape of their accumulated 
contents. Such consecutive, and often beneficial, hypertrophies are not 
confined to muscular organs, but may occur in glands, in bones, and else- 
where : in the kidney, for example, when in consequence of the destruction 
of one its fellow attains unwonted dimensions, or when both undergo 
enlargement under the influence of diabetes ; in the bones, as when a pro- 
tective buttress is formed in the concavity of a curved rickety tibia. 

Not all forms of hypertrophy, however, are a consequence of the attempts 
of organs to adapt themselves to conditions of increased work. Hyper- 
trophies which are essentially abnormal, and have no beneficial tendency 
whatever, arise, in some cases from the direct inflence of the nervous 
system ; in others (and these are the most frequent), from the stimulus of 
excessive supply of nourishment. Amongst the former may be included 
the hypertrophy of the heart which long-continued nervous palpitation in- 
duces, and that form of goitre which occurs in ' Graves's' disease ; amongst 
the latter, that general enlargement of the lower extremity (in which the 
bones get longer and thicker than those of its fellow, and the other struc- 
tures of the limb proportionately increased) met with in cases where, owing 
to obstruction and dilatation of its lymphatics, the whole member is suc- 
culent with nutritious fluid. A particular form of hypertrophy of the 
tongue in children, and the overgrowth of the skin and subcutaneous con- 
nective-tissue in elephantiasis, also are largely due to this last condition. 

3. Inflammation. 

General account. — The collective morbid phenomena which are included 
under this term occur as an essential, or as an accessory, part of the great 
majority of diseases. They represent the reaction of the system, or of 
parts of it, against the injurious effects of irritants which are morbid either 
from their amount or from their quality ; the efforts by which nature en- 
deavors to destroy, counteract, or throw out what is noxious ; and those 



60 



INFLAMMATION. 



by which she strives to repair what has been injured, and to restore what 
has been destroyed. It need scarcely be added that inflammation often 
goes far beyond, or falls far short of, its aim, and often acts as it were 
capriciously and blindly. 

The classical local signs of inflammation are redness, swelling, heat, and 
pain. These no doubt are all present in the majority of cases — the red- 
ness being due to accumulation of blood in the dilated bloodvessels ; the 
swelling, partly to this dilatation, partly to simple effusion and growth of 
tissue ; the heat, in some degree to the increased afflux of blood, in some 
degree to the rapid disintegration that is in progress ; and the pain to pres- 
sure on the sensory nerves, or to their implication in the morbid processes. 
But neither redness, swelling, heat, nor pain, is absolutely essential to in- 
flammation ; they are simply to be regarded as common results or accom- 
paniments of that process. 

Inflammation consists primarily and essentially in an unnatural irrita- 
bility, and tendency to undue proliferation, of the protoplasmic elements 
of a part — these giving rise, not as in simple hyperplasia, to a mere increase 
in the number of the normal elements, but to cells which tend to resemble 
leucocytes, or embryonic cells, and which never go beyond the formation 
of simple granulation-tissue or some variety or modification of the various 
forms of connective- tissue. The connective-tissue corpuscles are those in 
which inflammatory proliferation chiefly takes place ; but all protoplasmic 
masses, including those of the epithelia, those connected with the nerves 
and striped muscles, and also those which by their coalescence form the 
walls of capillary vessels, readily participate in the process. As doubtful 
exceptions may be named the special cells of the central nervous organs, 
the proper liver-cells, and other cells which have attained a high phase of 
development. 1 But, in connection with these extra- vascular changes, vas- 
cular phenomena speedily ensue, and at once take an active share in the 
processes which are going on. Among the incidents which occur in the 
course of inflammation or follow upon it are, exudation, suppuration, ulcer- 
ation, gangrene, and granulation or repair. 

a. Extra-vascular processes The extra- vascular processes of inflamma- 
tion may be best observed — observed freest from complication — in parts 
which are devoid of vessels, such as the cornea, cartilage, and certain 
portions of the mesentery. If a costal or articular cartilage be excited to 
inflammation by the mechanical removal of a bit of it, the injured surface 
becomes covered at the end of about a week by a soft, grayish pulp, which 
consists entirely of embryonic tissue, or a mass of embryonic cells, to- 
gether with some newly -formed bloodvessels. If now a cross-section of 
the cartilage be made, so as to include its whole thickness, together with 
the wounded surface and the pulp covering it, the following appearances 
will be detected on microscopic examination : first, in the region farthest 
removed from the seat of injury, the cartilage-cells and hyaline interven- 
ing substance in a perfectly normal condition ; but, on gradually advancing 

1 It is not intended to suggest, that these highly endowed cells are incapable of 
undergoing any form of inflammatory change, for recent observations by M. Charcot 
seem to prove that the proper cells of the nervous centres may be the primary and 
chief seats of such changes : still less that they take no active part in the non-in- 
flammatory morbid growth, for the investigations of Dr. Creighton tend to show 
that heterologous growths in the liver commence with vacuolation and internal 
gemmation of the proper liver-cells. 



EXTRA- VASCULAR PROCESSES. 



61 



thence to the diseased surface (second), simple enlargement of the cells 
and of their nuclei, and of the cavities in which the cells are contained ; 
third, fissiparous multiplication of the enlarged cells and nuclei, and the 
appearance therefore of several closely-packed nucleated cells in each 
originally unicellular cavity — each young cell, moreover, being invested 
in a thin cartilaginous capsule, and so still presenting the essential charac- 
ters of a cartilage-cell ; fourth, continued proliferation — the cells becom- 
ing smaller and much more numerous, losing their cartilaginous capsules, 
and assuming all the characters of simple embryonic cells, and the cavities 
containing each group of embryonic cells still enlarging at the expense of 
the hyaline cartilaginous substance, and hence approaching one another 
and here and there coalescing ; fifth, an irregularly scalloped border, to 
the whole surface of which is attached, and from the whole surface of 
which grows, the gray film of embryonic tissue covering the injured sur- 
face of the cartilage — each scallop representing a portion of a primitive 
cartilaginous capsule, the cavity of which has come to blend with those 
around it ; and the continuous embryonic mass representing the united 
proliferating contents of these and other lost cartilage-capsules. We thus 
see the effects of injury to be : first, growth and proliferation of the pro- 
toplasmic or living parts of the cartilage — the new-formed cells gradually 
losing the anatomical and other attributes of cartilage-cells, and degrading 
into simple embryonic cells ; and, second, progressive deliquescence and 
removal of the hyaline or non-vital constituent of the cartilage under the 
influence of this cell-growth and multiplication, culminating in its entire 
disappearance from those parts in which proliferation has attained its most 
advanced stage. 

The mesentery of the adult animal forms, not a uniform lamina, but a 
delicate network, of which the trabecular are in many cases exceedingly 
fine, without bloodvessels, and consisting solely of a core of connective 
tissue, and an investing layer of polygonal tessellated epithelium. If a 
little solution of nitrate of silver be injected into the peritoneal cavity of 
such an animal, inflammatory changes take place in that epithelium, as 
they have just been shown to take place under analogous circumstances in 
the cells of cartilage. At the end of about twenty-four hours, turbid fluid 
is found in the serous cavity — the turbidity being due to the presence of 
cellular elements, presenting all varieties between ordinary pus-corpuscles 
on the one hand, and larger cells containing two or more oval well-defined 
nuclei on the other ; and the epithelial cells at the surface of the trabecular 
have become plumper and larger, have lost their cell-walls, and in many 
cases have undergone proliferation, giving rise to pus-cells and such other 
forms of cells as are found floating in the peritoneal fluid. The cells ad- 
here irregularly to their points of origin, and are invested, and to some 
degree retained in situ, by bands of coagulated fibrin which has exuded 
from the inflamed surface. If no further irritation be excited, at the end 
of a few days the cells floating in the peritoneal fluid get opaque and fatty 
and perish, while those which are still adherent to the trabecular flatten 
and resume the ordinary characters of serous epithelium. 

In the above two cases we have proliferation simply of the cells which 
are proper to the irritated tissues ; in the case of the cornea, however, the 
results of irritation are more complex and more remarkable. The cornea 
of the frog consists mainly of a network formed by the union of the rays 
of stellate cells — the meshes being occupied by indifferent non-vital ma- 
terial, which corresponds to the hyaline matrix of cartilage, and to the 



62 



INFLAMMATION. 



white fibrous trabecule of ordinary connective-tissue. If the living cornea 
be irritated by the application of a point of nitrate of silver to its centre, 
changes presently take place in it, which soon spread, and before long in- 
volve the whole extent of its tissue, rendering it more or less obviously 
milky and opaque. The first changes discovered by the microscope are 
in the immediate vicinity of the injured spot. Here the stellate cells first 
become unnaturally- well defined, and a little more granular or turbid than 
in health ; then they swell, their branching processes at the same time 
growing thinner ; presently these are retracted, and the still-growing cells, 
assuming a somewhat nodulated or botryoidal form, become as isolated 
from one another in the substance of the corneal matrix, as are normally 
the cells of cartilage in the cartilaginous matrix. Whilst these changes 
are in progress the cells grow more and more opaque, and their contents 
more and more difficult to discriminate ; but soon, obvious proliferation 
occurs within them, the nuclei divide and subdivide — each subdivision 
carrying with it its own particular envelope of protoplasm — until every 
corneal cell becomes the mother-cell of an irregular group of embryonic 
corpuscles. This increase of the vital elements of the cornea is attended, 
as is the equivalent process in cartilage, by the liquefaction and removal 
of the intervening matrix, and ultimately by the coalescence of neighbor- 
ing groups of cells and their discharge from the surface of the organs. So 
far the process is essentially the same as in cartilage, and indeed as in 
serous membrane also. But something more occurs. Whilst the changes 
above described are going on in the centre of the cornea, and gradually 
spreading from that point outwards, other changes are taking place at the 
periphery of the cornea and creeping thence in the centripetal direction. 
These consist, in the gradual escape of leucocytes from the now dilated 
marginal vessels, and their immigration (in virtue of their amoeboid pro- 
perties) into the interstitial spaces of the adjoining parts of the cornea. 
These spaces they soon crowd, rendering the corneal tissue opaque ; and 
soon breed, mingling their offspring with those of the proliferating corneal 
cells, from which they become undistinguishable. Cohnheim, who first 
recognized this immigration of leucocytes into the inflamed cornea, at- 
tributes all the morbid cell-development occurring in it to their presence 
and action, and considers that the proper corneal cells remain perfectly 
passive. The active share, however, which these latter take in the in- 
flammatory process, has been so often witnessed and described by com- 
petent observers, that there can be no reasonable ground for doubt upon 
the matter. The concurrence of these two processes, not only in inflam- 
mation of the cornea, but in the greater number of inflammations, seems 
now to be thoroughly well-established. 

Processes, essentially identical with the above, mark the occurrence of 
inflammation in the inter-vascular spaces of the so-called ' vascular' tis- 
sues : they are, growth and multiplication of the protoplasmic elements, 
immigration and multiplication of leucocytes ; and, concurrently with this 
over-growth, the liquefaction or degeneration, and disappearance, of the 
non-vital parts, and indeed of living parts which have attained their highest 
phase of development. Thus, we find the earthy and organic matrix of 
bone eroded into cavities, the trabecular of white fibrous tissue attenuated 
into a comparatively delicate network, and muscular and nervous tissues 
undergoing fatty metamorphosis. 

b. Vascular processes — The condition of the bloodvessels in and about 
an inflamed part has long engaged the attention of pathologists. The 



VASCULAR PROCESSES. 



63 



important share which they take in inflammation is indicated by the red- 
ness which attends the process, and by the dilatation and throbbing of the 
arteries which lead to the spot in which it is going on. The latter fact 
indeed sustained, if it' did not originate, the belief that the increased flow 
of blood to an inflamed part was determined by the active movements of 
the vessels of the part, in the same way that the general distribution of 
the blood is governed by the alternate contractions and dilatations of the 
heart. 

That the active processes going on outside the vessels in an inflamed 
area create a demand for an increased supply of nourishment, has already 
been pointed out. This demand can only be satisfied through the medium 
of its bloodvessels, which consequently soon dilate, and thus attract thither 
an excessive amount of blood. This phenomenon, indeed, so speedily 
follows the event which calls it into operation, that in inflammation pro- 
duced experimentally it is often the very first indication of the presence 
of inflammation. If the web of a frog's foot, or its mesentery, or any 
other convenient tissue of one of the lower animals, be irritated, and the 
processes which follow carefully observed, it will be seen — that the small 
arteries of the irritated area, gradually dilate and probably after some hours 
attain their maximum diameter, which may be double that originally pre- 
sented by them ; that, subsequently to the commencement of the arterial 
dilatation, perhaps some hours afterwards, the capillaries and veins of the 
part follow suit ; and that thus at length all its vessels get proportionately 
enlarged. It will further be seen that, while these changes of dimension 
are going on in the vessels, equally remarkable changes are occurring in 
the blood-stream within them : at first while only the arteries are affected, 
the rate of flow is increased ; then, as general dilatation of the vessels 
supervenes, the stream flows more and more slowly through them (oscillat- 
ing, perhaps, in some of the capillaries), and the white corpuscles congre- 
gate and cling to the vascular walls ; at length the blood stagnates, and 
loses its serum, and the red and white corpuscles get wedged together into 
an apparently homogeneous or amorphous mass. While, however, this 
condition of stasis has been coming on in the area of inflammation, the 
vessels immediately around it have become dilated, and through them the 
blood is still circulating with unwonted rapidity. 

It is at the period of stasis, or rather perhaps just previous to it — at the 
time when the white corpuscles or leucocytes are adhering in large numbers 
to the inner surface of the vessels — that that emigration of corpuscles, 
which has already been adverted to, and plays so important a part in the 
inflammatory process, chiefly occurs, and may be best observed. If at this 
time the small veins be narrowly watched (for it is in them that the pro- 
cess commences and chiefly to them that it is confined) small, transparent, 
button-like bodies will be seen to spring here and there from their outer 
surface ; these gradually increase in bulk and number, and assume a pyri- 
form shape, and presently, having acquired the form and size of white 
corpuscles, detach themselves from the surface from which they seemed to 
grow — their connection therewith having previously been reduced to a 
mere thread. Prior to their complete detachment they often throw out 
delicate processes which aid them in their ultimate movements. In this 
way vast numbers of white corpuscles pass in a short time from the inte- 
rior of the vessels into the tissues external to them, without leaving behind 
them a trace of the route by which their escape through the parietes was 
effected. 



64 



INFLAMMATION. 



It is obvious, then, that variations in the dimensions of vessels, and in 
the rate of flow of blood through them, are very important incidents in 
the collective phenomena of inflammation. But it is not at all easy to 
determine upon what cause, or on what combination of causes, the several 
variations depend ; and especially it is difficult to trace the exact relation 
between the varying diameters of vessels and the varying rates of the pas- 
sage of their contents along them. We know that the smaller veins, and 
still more the smaller arteries, are capable of contracting and dilating within 
comparatively wide limits, and thus of regulating to a considerable extent 
the amount of blood to be admitted into, or discharged from, the area to 
which they minister ; and that this function is effected by means of their 
muscular walls, which, when they contract, diminish the calibre of the 
vessels, when they relax, permit of their dilatation. We now know also, 
chiefly through the labors of Strieker, that the capillary vessels are not 
merely passive organs, contracting and dilating in obedience to the various 
degrees of blood-pressure to which they are subjected ; but that, in virtue 
of the endowments of the living protoplasm of their walls, they possess, 
like the arteries and veins, a power of active contraction. And, further, 
we now have good reason to believe that arteries, veins, and capillaries 
possess, in addition to the power of active contraction and the capability 
of passive dilatation, a distinct power of active dilatation, or at any rate 
of dilatation with retention of tonicity. Again, we know that the muscu- 
lar tissue of the vascular system, like that of all other parts, is under the 
dominance of nerves — in this case the nerves of the vaso-motor system 
Contraction of vessels may be caused, either by the direct application of 
irritants to them, or by exciting the cut surface of the distal portion of a 
divided motor nerve, comprising vaso-motor fibres, distributed to them. 
Active or tonic dilatation seems specially to be induced by reflex action, 
excited by stimulating the sensory nerves of the part in, or near, which 
the vessels undergoing dilatation are situated. Passive dilatation takes 
place whenever the influence of the vaso-motor nerves is abolished or 
weakened, or the vascular walls lose their proper contractile power. We 
may gather from this statement, that the primary dilatation of the vessels 
of inflamed parts is due to reflex stimulation, traceable to the inordinately 
active vital processes which are taking place in the extra-vascular tissues ; 
and that the later dilatation is probably merely passive. As regards the 
question of the variations which take place in the rate of the blood-flow 
in the vessels of inflamed parts, it will be sufficient for our purpose to point 
out, that the increase, which occurs in the early stage of inflammation 
in the centre of the inflamed area, and which is maintained continuously 
in the immediate neighborhood of the lesion, is in obvious accordance with 
the physiological fact that dilatation of the smaller vessels, not only admits 
of a larger presence of blood in them, but allows of a more ready transit 
of blood through them ; and that the stasis, which takes place after a time 
in the still dilated bloodvessels of the inflamed area, is obviously connected 
with the tendency which the corpuscular elements of the blood have then 
acquired to adhere to, and pass through their walls — which conditions in 
their turn doubtless depend on the altered nutritive relations then subsist- 
ing, between the walls of the vessels and tissues external to them on the 
one hand, and the blood within them on the other. 

c. Exudation. — The abundant fluid which sweats from the vessels during 
inflammation, though consisting essentially of the serum of the blood, pre- 
sents modifications of constitution determined by the tissues in connection 



SUPPURATION. 



65 



with which its escape occurs, and further involves different results accord- 
ing to the circumstances attending its escape. The swelling, which always 
accompanies inflammatory processes going on in the substance of organs 
and tissues, is mainly dependent on this exudation ; and indeed if the parts 
involved be lax, serous infiltration, or oedema, is apt to spread far beyond 
the limits of actual inflammation. In inflammation of mucous membranes, 
the membrane itself, and the tissues which are subjacent to it, all get infil- 
trated; but, in addition, there is generally a copious discharge of fluid from 
the free surface. The most abundant discharge, however, takes place into 
serous cavities when the membrane which invests them is the seat of in- 
flammation. It is thus that hydrothorax and ascites are often produced. 
The most common distinction between inflammatory fluid-exudation and 
blood-serum is the presence in the former of a comparatively large quan- 
tity of fibrine, or fibrinogen. This is observed to a greater or less extent 
in all cases, but is especially remarkable in the inflammations of serous 
membranes, in which the great bulk of the exuded fibrine coagulates at 
the moment of its escape, entangling morphological elements, and forming 
the false membrane which adheres so characteristically to the surface. 
Another, but less frequent, peculiarity is the appearance in it of mucine ; 
this is observed chiefly when the mucous and synovial membranes are 
affected, and is due to the direct influence of the cells of the diseased sur- 
face. We have pointed out that the exudation of white corpuscles probably 
is an essential element in the inflammatory process ; small but variable 
numbers of red corpuscles also are apt to exude in company with them ; 
but at times the escape of blood-cells is much more abundant than can be 
explained by this process, and is manifestly due to actual rupture of blood- 
vessels — generally vessels of new formation. 

d. Suppuration. — A frequent event of inflammation, and one that marks 
one of its recognized stages, is the formation of pus. ' Laudable pus,' as 
it is termed, is a thick, creamy, mawkish-smelling, alkaline fluid, contain- 
ing a great abundance of corpuscles, to the presence of which its opacity 
and whiteness are due. The fluid part, which is called the ' liquor puris,* 
contains, like the serum of the blood (from which it is derived), albumen, 
salts, &c, and differs little from it in composition. It sometimes also pre- 
sents a peculiar albuminoid substance, named < pyine.' The corpuscular 
part consists almost entirely of bodies termed 4 pus-cells,' which, as gene- 
rally seen, are globular in form, varying between ^g 1 ^ and inch in 
diameter, and differing little, if at all, from leucocytes, or so-called 4 mu- 
cous corpuscles,' or embryonic cells. They are transparent, colorless, more 
or less granular masses of protoplasm, without investing membrane ; which, 
though globular when dead or as usually examined, present active amoeboid 
movements of locomotion and change of form, while still living and under 
appropriate circumstances. Under the influence of water, or still better 
dilute acetic acid, the general substance of each corpuscle swells up and 
becomes more transparent, and one nucleus, or more frequently two, three 
or even more nuclei, are revealed within it. 

It is obvious, then, that there is little or no microscopical difference be- 
tween typical pus-corpus"cles and the corpuscles developed, previous to the 
suppurative stage, by the breeding of connective-tissue cells and other sta- 
tionary protoplasmic bodies, or of immigrant leucocytes ; and that they 
both have a common origin. Indeed at every suppurating surface the 
gradual transition of the one into the other may be readily observed. 
There is, however, some reason to doubt whether pus-corpuscles ever mul- 



66 



INFLAMMATION. 



tiply, and some reason to believe that the groups of small nuclei they con- 
tain are to be regarded as the last abortive attempt at reproduction. 

It is not difficult to trace some of the steps which lead to the develop- 
ment of pus. It has already been shown, that when inflammatory pro- 
liferation is going on, the indifferent or non-vital tissues between the 
groups of swarming cells gradually get eroded and removed ; and that 
presently, as these disappear, the neighboring groups of cells come into 
direct relation with one another, and thus constitute an almost uniform 
mass of embryonic tissue. They still cohere, however, either as epithe- 
lial cells do, or through the intervention of some scanty adhesive material. 
It needs only the loss of this cohesive property, and the addition of the 
liquor puris, to convert this inflammatory hypertrophy of tissue into or- 
thodox pus. It is thus, indeed, that suppuration takes place at the surface 
of an ulcer ; it is thus, also, that abscesses arise. In the latter case, 
softening occurs in the centre of some proliferating region ; and the cells, 
which would otherwise have formed an ingredient of solid living tissue, 
change into pus-corpuscles ; by extension of the softening, the abscess en- 
larges, and more corpuscles are added to its contents ; and, further, the 
existence of a cavity induces towards it a rapid migration, both of the ex- 
travasated leucocytes, and of the other embryonic cells which crowd the 
periphery. By a continuance of the above processes, abscesses approach 
neighboring surfaces, point, and presently rupture. The pus-corpuscles 
contained within abscess-cavities speedily undergo degenerative changes, 
and perish — they get studded with fatty particles, swell, and subsequently 
break up into a detritus ; or they contract and become opaque and angu- 
lar; or they undergo calcareous impregnation. And thus the contents of 
abscesses are gradually, sometimes absorbed, sometimes converted into 
caseous, mortary, or other such stuff ; and a more or less perfect cure 
ensues. 

Pus of recent formation does not always present the exact characters 
above assigned to it, but sometimes is thin and watery (ichor), sometimes 
contains a greater or less admixture of blood (sanies), and sometimes is 
distinctly fetid. These obvious peculiarities are dependent on something 
special, either in the condition of the patient or in that of the part which 
is suppurating, and are connected with peculiarities of microscopical and 
chemical constitution. Thus, we find sometimes, that all the pus-corpuscles 
have already undergone degenerative changes, and that in place of the 
orthodox cells we have only granule-cells, or it may be a mere molecular 
debris ; sometimes, that abundant blood-corpuscles are mingled with the 
other elements of pus ; sometimes, that fragments of tissue, bone and the 
like, are contained in it ; and sometimes again, that bacteria and other 
minute living organisms, are present. The admixture of visible particles 
of tissue implies the association, with the suppuration, of somewhat rapid 
destruction of parts, and often indicates necrosis or gangrene ; the pres- 
ence of bacteria and the like is a proof, either that the pus is undergoing 
putrefaction, or that the blood generally is infected with them. Under all 
these latter conditions fetor is pretty certain to be present. 

e. Destructive processes — The destructive effects of inflammation have 
already been adverted to. They are shown in the softening and disinte- 
gration which take place in the hyaline substance of cartilage, in the 
white fibrous element of connective-tissue, and in the earthy matrix of 
bone, during the gradual multiplication of cellular elements, and es- 
pecially during the formation of abscesses. They are shown also in the 



ORGANIZATION AND GRANULATION. 



87 



fatty and other degenerative processes which, under similar circumstances, 
go on in muscle, nerve-cells, and other higher tissues, taking no part in 
the inflammatory proliferation. Destruction occurs, however, in a yet 
more marked form in the various processes termed ' ulceration' and ' ne- 
crosis' or 4 gangrene.' 

In gangrene a larger or smaller portion of tissue perishes, and is prob- 
ably separated in mass from the neighboring living textures. The death 
of the part is due essentially to its deprivation of nourishment ; which de- 
privation depends mostly on the obstruction of the arteries leading to it, 
either by clot in their interior, or by thickening of their walls, or by ex- 
ternal pressure arising from accumulation of inflammatory products or 
other causes. In inflammatory gangrene the parts involved usually are 
swollen and succulent, for the reason mainly that, like all inflamed tissues, 
they were previously infiltrated with abundant exudation. 

In ulceration the destruction of parts is molecular, or by small frag- 
ments, and progressive. It has long been a question whether, in the 
common forms of ulcer which gradually extend in area and in depth, the 
apparent melting away of tissue, on which their extension depends, is due 
to absorption by the vessels or to discharge from the surface. It is ob- 
vious, in any case, that this gradual disappearance of tissue must be pre- 
ceded by its liquefaction, degeneration or death ; for these are normal and 
necessary processes by which, even in health, the worn-out portions of the 
body are prepared for removal by absorption, and equally the processes by 
which, during inflammation unattended with ulceration, the more lowly- 
organized structures — the matrix of cartilage, cornea, bone, and the like 
— melt away and disappear ; and indeed it is impossible to conceive of 
any other. Looking then to the fact, that the molecular destruction, 
which is going on at the surface of ulcers, presents no real difference from 
that which is going on in the non-ulcerating stage of inflammation (the 
products of which are certainly removed in chief measure by absorption), 
it seems not improbable that a portion of the effete products of ulceration 
also may be removed in this way. But, on the other hand, since the de- 
struction takes place at a free surface, which is exuding a considerable 
quantity of fluid, and even of corpuscular elements — conditions which are 
highly favorable for the discharge from that surface of any effete matters 
which are produced there — it seems hardly likely that these should be re- 
moved by absorption only. Indeed it seems most probable, on physical 
grounds alone, that the chief removal of ulcerative detritus should be 
effected in the manner last described. That it is mainly thus removed is 
now generally acknowledged. It may be added, in confirmation of this 
view, that the discharge from ulcers involving bone contains earthy mat- 
ter, and even small fragments of bone ; and that generally when ulcera- 
tion is extending rapidly, fragments of disintegrated tissue are suspended 
in the fluids which exude from the ulcerated surface. In sloughing ul- 
cers, such as those attacked with hospital gangrene, extension is attended 
with an abundant separation of shreds and flakes of dead tissue from the 
diseased surface. 

It will of course be understood that the above remarks apply only to 
those cases in which ulceration is in progress. Excavations, whether 
termed ulcers or not, in which the surfaces are granulating are examples, 
no longer of ulceration, but of repair and restoration. 

f. Organization and granulation It has already been shown that, at 

an earlier stage than that at which suppuration occurs, the results of inflam- 



68 



INFLAMMATION. 



matory proliferation are the production of a greater or less quantity of 
embryonic tissue, or tissue at a low phase of organization. The interven- 
ing matters melt away, and the newly -formed cells come into near, if not 
absolute, relation with one another ; or, if the process is occurring at the 
surface of a serous membrane, the new-formed cells are retained in con- 
nection with that surface by entanglement in the fibrine which coagulates 
there. In the progress of organization important changes ensue. In the 
latter case the embryonic corpuscles, entangled in the fibrine, throw out 
delicate processes, by which they presently unite with one another to form 
a network, in the meshes of which the fibrine is then contained. At the 
same time, new vessels, starting from the normal vessels of the subjacent 
serous membrane, shoot into the adventitious tissue. Later, the fibrine 
undergoes liquefaction and removal, and the interspaces between the cells 
get occupied by a form of white fibrous tissue, which they are instrumental 
in manufacturing. In the case of the organization of inflammatory pro- 
ducts occupying the substance of organs, essentially the same series of 
events happen : the embryonic cells undergo conversion into connective- 
tissue corpuscles; new vessels are formed ; the fibrine which has coagulated, 
and in a greater or less degree the proper or special highly-endowed ele- 
ments of the parts, get removed or impaired, and the non-vital elements 
of connective-tissue are deposited in their place. In both cases, the new- 
formed tissue belongs to the connective-tissue series, and in both tends to 
get contracted and dense and hard in texture. 

The processes, here briefly described, take place also in "the healing of 
wounds, and in the filling up of ulcerous or other excavations by granula- 
tion. Granulations are hemispherical masses of cells, produced, and in- 
creasing in size, by constant cell-breeding and immigration of leucocytes. 
The cells in the first instances are purely embryonic in character, and many 
of those growing at the free surface, and others which migrate thither, are 
shed as pus. But presently those which remain undergo differentiation ; 
the majority elongate or send out processes and gradually evolve connec- 
tive-tissue ; whilst others also elongate, but become aggregated into solid 
cylindrical loops, soon to be hollowed into channels of communication with 
previously-existing vessels, and thus themselves to become bloodvessels, 
and important agents in the further growth and vitality of the granulation- 
tissue. Kindfleisch describes and figures the formation of lymphatic tissue 
in the over-grown vegetations of ' proud flesh.' Neighboring granulations, 
as they grow, run together and blend, and thus at length cavities get filled 
up with a tolerably homogeneous mass of new-formed tissue. But when 
the granulating mass attains the general level of a free surface, such as 
that of the skin, its further growth under ordinary circumstances becomes 
arrested, epidermis begins to shoot from the normal epidermis at the mar- 
gins over the edges of the granulating area, which at the same time con- 
tracts, and soon, if it be of small size, gets completely covered. It is 
even now a disputed point, whether a granulating surface has any power 
of itself to generate epidermic cells. It is certain, however, that the chief 
development, of new epidermis begins from old epidermis, that very large 
breaches of surface never become thus covered unless aided by artificial 
means, and that the grafting here and there, upon such a surface, of small 
fragments of epidermis results in the formation of a number of epidermic 
islets, from which new epidermis spreads radially. In the healing of a 
clean cut, of which the edges are placed in close apposition, the process is 
nearly the same as that of the organization of false membranes. The 



SPREAD — CONSTITUTIONAL EFFECTS. 



69* 



divided vessels pour out blood and serum, containing fibrinogen; and this 
coagulating entangles corpuscular elements, and cements the divided sur- 
faces ; presently the white corpuscles thus entangled, and others which 
migrate among them, emit processes and form a network, mapping out the 
fibrinous cement into comparatively small islets.- The further steps of the 
process present no peculiarity. 

The ultimate product of inflammatory organization is generally what is 
commonly termed i cicatricial tissue' — a form of connective tissue present- 
ing much hardness and compactness, comparatively little vascularity, small 
and widely scattered plasmatic cells, and relatively abundant and dense 
interstitial substance ; which becomes bony when developed in connection 
with bone, and contains fat when it replaces normal fatty tissue ; but which, 
while it is capable of reproducing, with more or less imperfection, the 
various tissues comprised in the connective-tissue group, rarely results in 
the reproduction or development of higher tissues, such as muscle, and 
probably never in the formation of organs. Hair and glands, for example, 
never appear in entirely new formed skin. 

In some cases the results of inflammatory proliferation are so'mewhat 
different- The process gets chronic, cell-generation goes on comparatively 
slowly, and the newly formed tissue, instead of contracting and harden- 
ing, becomes swollen and perhaps softer than natural, and forms, in fact, 
an increasing projection or lump, in which the cell-elements remain pre- 
dominant, but tend to fatty and other forms of generation. Such results 
are seen in keloid and in some forms of arterial atheroma. 

g. Spread. — The tendency which inflammations have to spread is at least 
as remarkable as that presented by other proliferating affections. If a 
patient has local eczema, produced by the application of some irritant, 
presently other patches of eczema appear in the neighborhood ; if he has 
a boil, it commences in a point, and increases by involving more and more 
of the surrounding tissues, and soon other boils arise in its vicinity; in 
erysipelas and pneumonia and in inflammations of serous and mucous 
membranes, the same rule of local spread, or spread by simple continuity, 
is even more obvious. But inflammations also tend, in many cases, to 
spread through the agency of the lymphatics and veins, and thus to in- 
volve remote parts, and other tissues besides those first affected. Thus, 
suppuration, occurring in a toe or finger, is apt soon to be followed by in- 
flammation in the course of the lymphatic vessels, and of the lymphatic 
glands in the groin or axilla ; and indeed generally there is a tendency, if 
the local inflammation be sufficiently intense, for the nearest lymphatic 
glands to get implicated. And thus again, in certain cases, inflammatory 
processes become generalized by means of the circulating blood, so that 
tracts of inflammation, secondary to some primary tract, appear, either 
simultaneously or in quick succession, in various parts of the body. Or- 
dinary pyaemia furnishes a typical example of this connection ; and it is 
not impossible that the frequent association of inflammation in different 
organs, and even the invasion of successive joints in acute rheumatism 
may admit of similar explanation. 

h. Constitutional effects. — We must not forget to consider, however 
briefly, the influences which inflammatory processes going on in one part 
of the system exert on the system generally. Patients who are suffering 
from acute inflammation are soon affected with febrile symptoms. To 
what are they traceable ? In some degree, no doubt, to the direct in- 
fluence which abundant local proliferation of tissue exerts generally upon 



10 



INFLAMMATION. 



nutrition. It will be recollected, however, on the other hand, that the 
copious and active proliferation attending the formation of an extensive 
surface of granulations, or the development of the foetus, produces no such 
constitutional disturbance. But, indeed, the inordinate consumption of 
nutrient matter is certainly not the main cause of the constitutional symp- 
toms of inflammation. It has been proved by direct observation that a 
part generates much more heat when inflamed than when in its normal 
state ; and that the blood in the veins coming from an inflamed area is 
distinctly hotter than the blood brought thither by the arteries. It is cer- 
tain, therefore, that a part of the febrile temperature of the system must 
be due to the dispersion of this excessive locally-produced heat. Again, 
as we have already pointed out, wherever inflammatory proliferation is 
active, there also the processes of effusion from the bloodvessels, of molecu- 
lar disintegration, and of lymphatic absorption are specially active ; and 
thus large quantities of modified nutrient fluid, and of products of decay, 
alike, are being constantly removed from the seat of disease and poured 
through the thoracic duct into the systemic veins. It seems highly prob- 
able that here is the source of the comparatively large presence of fibrino- 
gen which is so characteristic a feature of the blood of inflammation, and 
that here also is the main source of the excess of urea and other products 
of retrograde metamorphosis, which are presently discharged by the vari- 
ous emunctories. There can be no doubt that the general symptoms of 
inflammatory fever are largely due to the heightened temperature, and to 
the alteration and deterioration of the blood, which have been thus pro- 
duced — conditions which, according to their amount, must necessarily in- 
fluence in a greater or less degree the nutrition and the functions of all 
parts of the system. It is certain, too, that the nervous system, mainly 
by its vaso-motor branches, plays an important part in the production of 
febrile disturbance, though what that part is is not easy to identify ; and 
that the symptoms of inflammatory fever are largely modified, chiefly in 
the way of complication, by the interpolation of other symptoms, due to 
the modification, impairment, or destruction of the normal functions of the 
organ which happens to be affected. 

i. Varieties — In the foregoing pages we have discussed the phenomena 
of inflammation in the abstract; our account of inflammation would 
scarcely be complete, however, if we failed to point out some of its varie- 
ties — varieties depending, partly on the intensity of the process, partly on 
the organ implicated, and partly on the nature, and mode of operation, of 
the cause; and revealing themselves as such, either by their extent and 
arrangement, or their special tendencies, or their duration. It need 
scarcely, perhaps, be pointed out, that we trench here upon the domain of 
specific diseases, or diseases in which the inflammation is a mere secondary 
phenomenon, excited and kept up by the operation of some specific irri- 
tant, which has been received into the system and then distributed through 
it. But indeed, as knowledge advances, we see more and more clearly 
that, in every case of inflammation which comes before us, the inflamma- 
tion has been excited by some cause which imparts to it certain distinc- 
tive features — that it is specific — and we recognize the fact, half uncon- 
sciously perhaps, by distinguishing most varieties of inflammation by 
specific names. 

First. Varieties as to extent and arrangement. — In many cases, inflam- 
mation pervades, with tolerable uniformity, the whole of an organ or tissue — 
such is the case in pneumonia, peritonitis, erysipelas, and pityriasis rubra; 



VARIETIES. 



u 



in many cases, it is irregularly distributed in patches or spots, as in the 
rashes of typhus and enteric fevers, in urticaria, shingles, and lobular 
pneumonia; in other cases, it assumes certain definite patterns — disks in 
lepra, rings in erythema circinatum, and ringworm, crescents in measles, 
and sinuous bands in some cases of secondary syphilis. 

Second. Varieties as to result and intensity It is certainly a striking 

fact, that some forms of inflammation, no matter how severe they may 
seem, or threaten, to be, never pass beyond the earlier stages of the pro- 
cess; while others, which commence probably with the mildest indications, 
invariably go on to suppuration or gangrene. In such diseases as measles, 
pityriasis, and lepra, the local phenomena of inflammation are always ex- 
ceedingly slight, and consist in little more than hyperemia in patches, 
followed by modification, and then detachment, of the over-lying epider- 
mis. In urticaria, the process, if more intense for the time, is far shorter 
in its duration; for here we get pretty intense congestion, with rapid effu- 
sion of serum into the congested tissues, which subsides in a few hours or 
even in a few minutes, and is rarely followed even by desquamation. In 
eczema, herpes, and pemphigus, the local congestion is always attended 
with abundant effusion of serum beneath the epidermis. Now, in all the 
above cases, notwithstanding the marked differences of detail which they 
exhibit, the changes are rung only on mere congestion and effusion, to- 
gether with (as is of course always the case) a certain amount of nutritive 
change, if not of actual proliferation. In other cases, suppuration seems to 
occur almost invariably; it is so with smallpox and cowpox, impetigo and 
ecthyma; and in inflammation affecting the periosteum, and the womb 
immediately after parturition, this suppurative disposition is extremely 
well-marked. In other cases, again, the tendency of the inflammation to 
end in the death of tissues, that is, in ulceration or gangrene, is a charac- 
teristic feature; as examples we may adduce erysipelas, carbuncle and 
hospital gangrene. 

Third. Varieties as to duration — Inflammations are acute or chronic 
in their progress. Acute inflammations are sometimes, as in factitious 
urticaria, remarkably evanescent. Chronic inflammations are chronic in 
different fashions : — in some instances the inflammatory process, as in the 
case of a patch of psoriasis on one of the knees, or of a sinus constantly 
discharging pus, is continuous and of long duration ; in a larger number of 
cases chronicity is due to a succession of acute attacks, each one of which 
may have but little intensity. It is thus that urticaria assumes the chronic 
form of urticaria evanida, and that erysipelas and eczema become per- 
petuated ; we may add to the list rheumatism and gout. It seems probable 
also that cirrhosis of the liver, referable to alcohol, is rendered chronic by 
the repeated irritation induced by the repeated application of the alcoholic 
poison. It is in these latter forms of chronic inflammation, more especially, 
that the proliferation of tissue, which attends all inflammations, becomes 
constant, and leads to a substantial addition to the normal bulk of a part ; 
that bones acquire increased thickness and density ; and that the interstitial 
tissue of the liver, kidneys, lungs, and nervous centres gets augmented in 
quantity, and by its augmentation leads to the gradual destruction of the 
essential glandular elements. 



12 



TUMORS. 



4. Tumors. 

General Account It would be foreign to the purpose of this work, and 

to a great extent out of place, to enter into anything like a minute account 
of the various forms of tumors which are described by pathologists. We 
purpose, however, to pass them generally in brief review — describing at 
greater length those of them which have a special relation to the practice 
of medicine, and a special interest therefore for the physician. Tumors, 
in the proper sense of the term — that is, morbid proliferating growths, or 
neoplasms — have a very close affinity with simple hypertrophy or hyper- 
plasia on the one hand, and with mere inflammatory overgrowth on the 
other. Structurally considered, they are in truth, in many cases, a simple 
hyperplasia or overgrowth of normal tissue, differing, however, from true 
hyperplasia in the facts — first, that they are overgrowths occurring in a 
limited district ; and, second, that their growth has no relation to the 
general growth of the tissue out of which they spring, or to the general 
nutrition of the body. In many cases, again, tumors and simple inflam- 
matory overgrowths are structurally identical ; but generally the latter are 
more rapid in their development than tumors are, and, at the same time, 
much more ephemeral in their duration. 

Tumors have been variously classified. They have been divided into 
the two large groups of cystic and solid tumors. But cysts, although a 
very characteristic feature of some new formations, are for the most part 
merely incidental to them, and their presence or absence can in no sense 
furnish the basis of a scientific classification. Again, they have been dis- 
tinguished into those which are innocent and those which are malignant. 
It need scarcely be said, that the question of the malignancy or non-ma- 
lignancy of a tumor is always, in a practical point of view, of supreme 
interest; and it may be allowed that, in a large number of cases, malig- 
nancy is linked to special structural characters, and may be predicted from 
them. But, on the other hand, it is now generally admitted that malig- 
nancy varies in degree, and that few if any proliferating growths are wholly 
free from liability to assume malignant properties. Virchow, accepting the 
law which J. Miiller enunciated — namely, that ' the tissue which consti- 
tutes a tumor has its type in one of the tissues of the organism, either in 
its embryonic condition or at the period of its complete development' — 
classifies tumors according to their structural relations with the normal 
tissues of the body. Such a classification is at once scientific and intelli- 
gible; and although many difficulties, and much room for difference of 
opinion, present themselves when it is attempted to carry it out in detail, 
there can be little doubt that it is sound in principle, and will ultimately 
be universally adopted. But, admitting that all tumors have their types 
in the normal tissues, it does not always happen that a tumor has its type 
in the very tissue in which it originates. When a tumor arises in a tissue 
from which it takes its pattern, it is regarded by Virchow as ' homolo- 
gous;' when, on the other hand, it is developed in a tissue which it does 
not thus resemble, he calls it ' heterologous.' The latter term has often 
been used of malignant tumors, in the belief that they are something alto- 
gether different and distinct from the normal elements of the body — some- 
thing in fact of the nature of parasites ; and it is well to know that, even 
in the more accurate and limited sense in which Virchow employs it, it 
still carries with it the sense of malignancy. Most malignant tumors are 
heterologous. 



CLASSIFICATION OF TUMORS. 



73 



Virchow divides tumors into four groups, as follows : 1, tumors formed 
at the expense of the elements of the blood, or tumors by extravasation 
and exudation ; 2, tumors referable to the retention of products of secre- 
tion, and the consequent dilatation of ducts or cavities ; 3, tumors origi- 
nating in proliferation, which he subdivides into histioid tumors, or such 
as are formed out of a single tissue, organoid, or such as are characterized 
by greater complexity and an approach to the structure of organs, and 
teratoid, or those comprising a combination of organs ; and 4, or lastly, 
complex tumors, in which features characteristic of two or more of the 
foregoing groups are combined. The first two of Virchow's groups em- 
brace a series of pathological results which can only be regarded con- 
ventionally as tumors ; all true tumors are included in his third and fourth 
groups. 

We shall not discuss the details of the above classification, nor shall we 
reproduce here the convenient modification of it which MM. Cornil and 
Ranvier have published ; yet, in the brief account of tumors which we 
are about to give, we shall be guided in a very great degree by the views 
of these authors. Indeed, the modifications, mainly of arrangement and 
proportion, which w T e shall introduce, will have reference almost entirely 
to convenience of description and to clinical considerations. We shall 
arrange tumors (omitting, as will be observed, all further reference to the 
teratoid and complex forms) in the following groups : — 

a, tumors which have their type in the various forms of connective 
tissue ; this includes the fibrous tumor or fibroma, the fatty tumor or 
lipoma, the mucous-tissue tumor or myxoma, and one or two less import- 
ant varieties; 

b, tumors composed of cartilaginous tissue, or chondromata ; 

c, osseous tumors, or osteomata ; 

d, tumors formed of nervous tissue, or neuromata ; 

e, tumors consisting of muscular tissue, or myomata ; 

f, vascular tumors, or angiomata ; 

g, tumors consisting of lymphatic tissue, or lymphomata ; 

h, tubercle and granuloma, including syphilitic gummata, and farcy ; 

i, sarcomata, or tumors which resemble embryonic tissue ; 

j, tumors presenting an alveolated structure — the alveoli being formed 
of connective tissue, and occupied or lined by closely packed epithelium- 
like cells ; all these are embraced in the general term ' carcinoma' or 
' cancer.' 

a Connective-tissue Tumors. 

i. Fibrous tumor, or fibroma Tumors of this kind consist essentially 

of connective tissue — that is, of a network of plasmatic cells, separated 
from one another by bundles of white fibrous tissue and different propor- 
tions of elastic fibres ; the last, indeed, are often absent. They are rosy, 
grayish, yellowish, or white in tint ; are sometimes dense and close-grained 
like fibro-cartilage, sometimes soft, loose in texture, and succulent; are 
provided for the most part with scanty and small bloodvessels, and are 
sometimes non-vascular ; and very often, when involving a mucous or a 
serous surface, involve also the glandular and papillary structures, which 
then undergo hypertrophy. Fibrous tumors often originate in the subcu- 
taneous connective tissue ; often, too, in the substance of the skin — pro- 
ducing, sometimes warts or papillomata, sometimes ' molluscous' tumors, 



TUMORS. 



and sometimes pedunculated masses of enormous bulk. Again, they are 
frequently developed in connection with mucous surfaces, forming mucous 
polypi. The opaque cartilage-like patches often seen on the surface of 
the spleen, heart, and other viscera, are fibromata ; but their plasmatic 
cells are scanty, indistinct, and much flattened, the fibrillated intermediate 
substance is densely stratified, and they are without vessels. The thick- 
ening and induration of the skin and subcutaneous connective tissue, in 
elephantiasis Arabum, are chiefly due to the growth of connective tissue, 
and constitute a diffused form of fibroma. It is very difficult to separate, 
by a defined line, the results of chronic inflammation from fibromatous 
tumors, especially from the diffused forms of fibroma. And, indeed, papil- 
lary growths and polypi are frequently a simple sequela of ordinary in- 
flammatory processes ; and further, there is little if any real difference 
between the forms of fibroma involving the pyloric extremity of the sto- 
mach, or the substance of the mamma, which we generally regard as of 
the nature of tumors, and the fibrous growth invading the liver in cirrhosis, 
which is commonly considered to be simply inflammatory. Fibrous 
tumors are apt to undergo various forms of degeneration, especially the 
fatty, mucous, and calcareous. They are almost invariably free from 
malignant tendency. 

ii. Fatty tumor, or lipoma. — Fat is a mere modification of connective 
tissue, in which the plasmatic cells have become distended with oil, so that 
their protoplasm and nuclei can only be recognized with difficulty, and they 
themselves are transformed into globular, or (from mutual pressure) poly- 
hedral, bodies. Fatty tumors consist, for the most part, simply of newly- 
developed fat tissue, and present little if any structural differences from 
normal fat. They vary in size, and generally are lobulated, and capable 
of pretty easy enucleation from the tissues in which they are imbedded ; 
but sometimes their limits are ill-defined, and they pass gradually into the 
normal textures. Lipomata often originate in the subcutaneous connec- 
tive tissue, and occasionally in the submucous and subserous tissues ; also 
in the neighborhood of glandular organs ; and indeed generally wherever 
fat exists naturally. Not unfrequently they form polypi or pedunculated 
tumors. There are several well-defined varieties of fatty tumors : one, 
which may be called fibrous lipoma, is characterized by the presence of 
abundant fibrous tissue ; another — the myxomatous lipoma — presents the 
combined characters of myxoma and lipoma ; a third is the cystic lipoma ; 
and the last which we may enumerate is the erectile or cavernous lipoma. 
Further, fatty, like fibrous tumors (to which they are closely related), are 
liable to undergo calcareous and other forms of degeneration, and are pro- 
bably always innocent. 

iii. Mucous tumor, or myxoma, Mucous tissue, which is common in 

the foetus, exists permanently only in the vitreous humor. The tissue of 
the umbilical cord furnishes a typical example of it. It consists of plas- 
matic cells, which are generally stellate like those of connective tissue or 
bone, and of an intercellular substance, which, instead of being solid, as in 
these latter cases, is transparent and fluid and contains mucine, or the 
characteristic constituent of mucus. Myxomata are lobulated tumors, 
gelatinous in consistence, translucent, and yielding a transparent, glairy, 
never milky, fluid. Under the microscope they are seen to consist of scat- 
tered cells, sometimes round or oval, often stellate, and an abundant net- 



CARTILAGINOUS TUMORS. 



75 



work of capillary vessels, separated from one another by the structureless 
fluid, or semi-fluid, mucus which gives them their specific character. 
They vary in color and consistence according to the relative proportions of 
cells and mucus which they contain, being more opaque and denser as the 
cellular element predominates. They originate in most places in which 
normal fat occurs, and indeed there seems to be some definite relation be- 
tween them and fat. But they occur elsewhere. Their most common 
seats are the subcutaneous and submucous tissues, and the connective web 
between muscles ; but they are not unfrequently met with in the brain and 
in the course of nerves, in glandular organs such as the breast and kidney, 
and beneath the periosteum. In connection with the skin and mucous 
membranes, they often form papillary or polypoid outgrowths. Placental 
hydatids are a good example of this latter variety. Sometimes myxomat- 
ous tumors contain cavities (cystic myxoma), or their cells get distended 
with fat (lipomatous myxoma), or their intercellular mucus tends to con- 
dense and become cartilaginous (enchondromatous myxoma), or their 
vessels are extraordinarily abundant and large (vascular or erectile myx- 
oma). Myxomata, when not occurring in situations where fat is normally 
present, must be regarded as heterologous ; and they then occasionally 
present malignant characters. Generally, however, they are innocent, and 
do not even return after removal. 

iv. Glue-like tumor, or glioma — This is a tumor which, according to 
Virchow, consists of connective tissue resembling that of the nervous cen- 
tres ; and in fact it originates almost exclusively in these centres, in the 
course of nerves, and in the retinas. The neuroglia consists of very small 
and delicate cells, imbedded in a finely granular or amorphous substance. 
These have a tendency to be stellate, and, in carefully prepared sections, 
appear to unite with one another by their rays, so as to map out the inter- 
vening substance into small polygonal arese. Gliomatous tumors present 
the same structure, and are generally white and medulla-like in aspect, 
and exceedingly soft. They vary no doubt considerably, in respect of the 
relative proportions of their cellular and intercellular elements, and in 
their tint, consistence, and vascularity ; and they run, on the one hand, 
into myxoma, on the other into the small round-celled variety of sarcoma, 
with one or other of which it is difficult to avoid confounding them. They 
are apt to undergo mucous, caseous, or fatty degeneration, and to become 
cystic. The situations which they affect, and the tendency they have to 
attain a large size, render them dangerous ; but they are rarely malignant. 

b Cartilaginous Tumors, or Chondromata. 

Chondromata consists of cartilaginous tissue — that is of cells surrounded 
by lamellated thickenings, and separated from one another by intercellular 
substance, yielding chondrine, which is generally hyaline, as in ordinary 
auricular cartilage, but may be reticulated as in yellow cartilage, or fibrous 
as in fibro-cartilage. Cartilaginous tumors have for the most part a slightly 
translucent or pearly aspect, and a whitish, grayish, or yellowish hue. 
They vary greatly in consistence, being sometimes dense and hard and 
crisp, sometimes forming a diffluent pulp. They are generally distinctly 
lobulated, the lobules being separated one from another by connective 
tissue, which conveys their nutrient vessels ; for the cartilaginous tissue 
itself is entirely extra-vascular. The tumors are often perfectly well- 



76 



TUMORS. 



defined ; but they are sometimes irregularly diffused through the tissues or 
organs in which they originate. Under the microscope they present many 
varieties of character. Their cells vary in size and number, and are 
always encapsuled ; they are generally round or oval, but occasionally 
branched or stellate like those of the cornea ; further, they not unfrequently 
undergo fatty or calcareous degeneration. The intercellular substance, 
which, as previously stated, may be hyaline in character, or consist in part 
of either white fibrous tissue or elastic fibres, sometimes softens into a 
mucous fluid in which the cartilage-cells are simply suspended. Chon- 
dromata in this latter condition have a resemblance to the intervertebral 
cartilages ; and it is by such softening in patches that they occasionally 
become cystic. Virchow divides chondromata into ecchondroses and 
enchondromata. The former are merely outgrowths from the normal car- 
tilages, and are therefore homologous ; they never attain important dimen- 
sions, are invariably innocent, and very apt to be converted into true bone. 
The most interesting examples of ecchondrosis are the cartilaginous out- 
growths which take place in joints affected with chronic rheumatoid 
arthritis. Enchondromata are heterologous ; they occur most frequently 
in bones, especially in the long bones ; but they are also met with in the 
subcutaneous connective tissue, and in the aponeuroses, in the lungs, paro- 
tids, testicles, ovaries, and mammary glands. Enchondromata generally 
no doubt are innocent ; but they certainly are sometimes distinctly malig- 
nant, extending along lymphatic vessels, involving lymphatic glands, and 
ultimately invading remote organs. 

c Osseous Tumors, or Osteomata. 

Osteomata are generally divided into three species — namely, ivory osteo- 
mata, compact osteomata, and spongy osteomata. The first species is met 
with on the inner surface of the skull, and at the joint ends of bones and 
elsewhere ; it is characterized by remarkable compactness of tissue, and 
under the microscope presents bone-corpuscles and canaliculi (which latter 
run radially to the surface), and a total absence, or great deficiency, of 
Haversian canals, and hence of vessels. Compact osteomata present the 
ordinary characters of compact bone. Spongy osteomata, as their name 
implies, resemble more or less closely the spongy or cancellous tissue. Os- 
teomata springing from the surfaces of bones are known as exostoses; 
those originating in the substance of bones may be named enostoses. Both 
varieties are clearly homologous. But osseous tumors are sometimes hete- 
rologous. Thus, they appear in the connective tissue, in the membranes 
of the brain and cord, in the brain itself, in the choroid and vitreous 
humor of the eye, in the lungs and in the skin. True osteomata, even 
when heterologous, are probably never malignant. Nevertheless tumors, 
which have undergone more or less perfect conversion into true bone, are 
sometimes malignant in a very high degree. Such tumors, however, are 
made up in great measure of cartilaginous or embryonic tissue, and should 
probably be regarded as chondromata or sarcomata which have undergone 
calcareous or osseous transformation. 

The teeth occasionally present outgrowths of their own tissue, which 
have been named odontomata. 



NERVOUS AND MUSCULAR TUMORS. 



77 



d Nervous Tumors, or Neuromata. 

The term i neuroma' is often applied loosely to all growths occurring in 
the course of nerves ; and thus myxomatous, fibrous, and various other 
equally distinct tumors have, to a large extent, been regarded as varieties 
of neuroma. Neuroma, in the strict sense of the word, means a tumor 
formed of nervous tissue — either vesicular like that of the ganglia or cen- 
tral nervous organs, or fasciculated like that of the nerves or medullary 
substance of the brain. The former variety is exceedingly rare, but has 
been described as occurring in the brain and spinal cord. The latter 
variety is more common, but nevertheless of unfrequent occurrence, and 
is met with only in the course of nerves. True fasciculated neuromata 
generally are small white hard tumors, occurring singly or in numbers 
along a nerve-trunk, or more commonly at the extremities of nerves, which 
have been divided in the amputation of a limb. They are invested with, 
and permeated by, very dense fibrous tissue, the presence of which makes 
them difficult of examination ; but their essential character is, that they 
contain a large number of newly-developed nerve-fibres, which form an 
abundant and intricate network. These generally have the double con- 
tour ; but neuromata containing only pale fibres have been described. 

e Muscular Tumors, or Myomata. 

Striped muscular fibres have been discovered only in congenital tumors. 
Unstriped muscular fibres, on the other hand, are of common occurrence 
in morbid growths. Myomata are most frequently met with in the uterus, 
and it is in connection with the uterus that their characters may best be 
studied. The so-called 4 fibrous tumors' of this organ are, almost without 
exception, muscular tumors. These vary greatly in size, have a reddish 
or grayish fleshy aspect, are generally exceedingly dense, and present a 
lobulated character with curvilinear bands of fibres interlacing with great 
complexity. They always originate within the walls of the uterus, and 
hence, in the early stage, are surrounded by the uterine muscular tissue ; 
but if seated near either the mucous or the serous surface, they are apt ere 
long to protrude through the fibres which embrace them on that side, and 
presently to become pedunculated. Microscopically, they are found to be 
identical in structure with the uterine muscular walls. Further, like them, 
they are capable of hardening in contraction, and again of undergoing relax- 
ation. Moreover, they increase during pregnancy as the uterus itself in- 
creases — their muscular fibres undergoing similar and equal hypertrophy ; 
and when, after parturition, the uterine walls suffer involution they also 
suffer in the same sense. Uterine muscular tumors frequently degenerate : 
the muscular fibre-cells get fatty ; or their tissue undergoes mucous trans- 
formation — considerable patches becoming softened and infiltrated with 
mucous fluid, and not unfrequently converted into cysts ; but the most 
frequent and important change is due to the deposition of calcareous mat- 
ter, partly in the connective tissue of the tumor, partly in its muscular 
fibres, by which means nearly its whole substance may at length be con- 
verted into a hard calcareous mass. This latter form of degeneration 
generally commences in the interior ; occasionally, however, it starts from 
the periphery, and it may remain limited to the periphery. Myomata 
rarely, if ever, originate except in tissues which themselves contain mus- 



78 



TUMORS. 



cular fibres. After the uterus, they are most frequently met with in the 
prostate, and alimentary canal. They have also been found in the scrotum, 
labia majora, and ovaries. They are always innocent. 

f. — Vascular Tumors, or Angiomata. 

Several of the tumors which have already been described, and several of 
those which we shall presently discuss, are liable to be exceedingly vas- 
cular — partly from excessive formation, partly from general and irregular 
dilatation, of bloodvessels — and thus to assume an erectile or cavernous 
character. And, indeed, although we have adopted the name ' angioma' 
for a group of tumors, there are few, if any, in which vascular hypertrophy 
or hyperplasia constitutes the sole, or even the essential, characteristic. 
Angiomata may be conveniently divided into two species, in the one of 
which the newly-developed vessels are properly formed arteries, veins, and 
capillaries, and, in the other of which the blood traverses a series of lacu- 
nar spaces, like those of erectile organs. The former may be called 'sim- 
ple angiomata,' the latter ' cavernous angiomata.' Simple angiomata, form 
violet or red, more or less elevated, patches, the general seat of which is 
the skin or subcutaneous connective tissue. Their vessels are abundant, 
tortuous and dilated, and often present irregularities of calibre, and even 
pouch-like protrusions. Amongst these must be reckoned the small race- 
mose knots, which often make their appearance on the face and elsewhere 
— sometimes in considerable numbers — and in which the chief morbid 
phenomenon is dilatation of small arteries and veins. Cavernous angio- 
mata are also known by the name of erectile tumors. They occur in the 
skin and subcutaneous connective tissue, in the neighborhood of the ex- 
ternal mucous orifices, and in some of the internal organs, more especially 
the liver and spleen. They have a spongy character, which is due to the 
comparatively large size of their vascular lacunse, and the comparatively 
small amount of their solid tissue. The lacunae are irregular in size and 
shape, communicate freely with one another, and are lined with a layer of 
flat epithelial scales. The solid or trabicular element consists mainly of 
connective tissue, in which the ramifications of small vessels and unstriped 
muscle are sometimes contained. Angiomata are often congenital, and are 
entirely free from malignancy. 

g — Lymphatic Tumors, or Lymphomata. 

The important relation which subsists between the lymphatic vessels 
and glands, on the one hand, and morbid proliferation of tissue, on the 
other, has already been explained. Wo have shown that, when inflamma- 
tory processes are taking place in any part, the nearest lymphatic glands 
tend very soon to get inflamed ; that, if the local inflammation has specific 
characters, the resulting affection of the lymphatic glands shares in these 
characters; and that, in all cases of malignant tumor, it is the neighboring 
lymphatic glands which, next in order of sequence, become the seat of 
malignant growth. So that, in fact, in the morbid proliferations of these 
bodies, we have an epitome of the morbid proliferations of the whole 
organism; and to describe their tumors would be equivalent to writing 
a complete treatise on tumors. "What is meant, however, by the term 
lymphatic tumor, or lymphoma, is an hypertrophy or hyperplasia of lymph- 
atic structure, and the new formation of similar structure in parts where 



LYMPHATIC TUMORS. 



79 



normally lymphatic organs have no existence. Under the name 4 lymph- 
oma' may be included two perfectly different morbid conditions : — the one, 
an abnormal development of lymphatic vessels, or lymphangioma ; the 
other, an abnormal development of lymphatic gland-structure, or lympha- 
denoma. 

i. It is doubtful if lymphangioma, as an independent morbid growth, 
has any existence. There are many cases, however, in which enlargement, 
and possibly over-development, of lymphatic vessels forms an important 
ingredient in the morbid conditions which are present. Virchow has 
shown that, in elephantiasis Arabum, hyperplasia of the connective tissue 
is largely associated with a dilated and hypertrophic state of the lymphatic 
vessels, and especially of the lymphatic spaces in which they originate. 
This change, seems, however, to be secondary to obstruction of the lymph- 
paths through the inflamed lymphatic glands, to which the dilated tubes 
converge. In congenital hypertrophy of the tongue and lips, the same 
authority has pointed out the presence of a similar condition of the lingual 
lymphatic vessels. Further, cases are occasionally observed, in which the 
penis and scrotum, or corresponding parts in the female, or the lower part 
of the abdomen, or the thigh or leg, are thickened and brawny; and in 
which groups of depressed vesicles appear here and there, and, rupturing 
from time to time, yield large quantities of pure lymph. Here, the hyper- 
trophy of the skin and subjacent parts, and the formation of vesicles, are 
doubtless all due to dilatation of the lymphatics, and their distension with 
lymph — phenomena which probably are themselves secondary to some 
proximal obstructive disease. 

ii. Lymphadenoma, There are at least three morbid conditions of the 

lymphatic glands which, if we have regard only to anatomical characters, 
are extremely difficult, and often impossible, to distinguish from one an- 
other. These are — simple inflammatory hyperplasia, the so-called ' scrofu- 
lous' form of enlargement, and that morbid condition now generally known 
as lymphadenoma, or lympho-sarcoma. 

Simple inflammation of lymphatic glands may be induced by causes 
acting directly upon them, but is much more commonly the result of irri- 
tation propagated to them along the lymphatic vessels. They enlarge and 
get painful, assume a homogeneous aspect and a yellowish or faint rosy 
tinge, and under the microscope are found to differ but little from healthy 
glands — their enlargement being due to simple hyperplasia of their cell- 
elements, or leucocytes, and hypertrophy of their reticular connective 
tissue. Lymphatic glands thus affected may suppurate, or undergo other 
of the changes which are apt to follow on inflammation ; but their general 
tendency is to resolution. 

The term ' scrofulous'' is commonly applied to the slow and painless en- 
largement of groups of lymphatic glands, which occurs for the most part 
in children, and almost invariably ends in the destruction of the glands by 
an imperfect kind of suppuration. Scrofulous glands are generally met 
with in either the neck, thorax, or abdomen, and are commonly limited to 
one of these regions. Indeed, in the neck, where their progress can best 
be followed, we often see that the enlargement commences in one gland 
only ; that the glands in the vicinity are successively affected, and often 
at long intervals ; and that, after a while, the morbid process ceases with 
the destruction of all the implicated glands — those on the opposite side of 



80 



TUMORS. 



the neck possibly remaining all the time perfectly healthy. In the earlier 
stages of this affection, the glands differ little, either to the naked eye or 
under the microscope, from such as are simply hyperplastic from inflam- 
mation ; but they tend soon to become opaque, yellow and friable — to un- 
dergo caseous degeneration. This change commences in the central parts, 
and gradually involves the whole mass, which presently breaks down into 
a semi-fluid detritus and thus forms the imperfect pus previously adverted 
to. Occasionally the caseous lump dries up, earthy salts are deposited in 
it, and it becomes an inert earthy concretion. There is a good deal of 
vagueness in the sense in which the term ' scrofulous' is generally em- 
ployed. It is taken for the most part to imply that the morbid process, to 
which we attach it, is dependent on some peculiar condition of the con- 
stitution, and further that there is some close affinity, if not actual iden- 
tity, between it and tubercle. But the so-called 4 scrofulous glands' are 
certainly not tubercular ; and, although their appearance is sometimes fol- 
lowed by that of tubercle, in a very large number of cases no such sequence 
is observed. [This opinion is at variance with that expressed by Rind- 
fleisch in his recent article on Chronic and Acute Tuberculosis, in Ziems- 
sen's Encyclopedia. In this author's opinion, scrofulous glands are al- 
ways tubercular glands. ' The grayish parenchyma of a scrofulous gland 
which has not yet become cheesy, is,' he says, ' studded not merely with 
a few giant cells, but with a considerable number of veritable tubercules.'] 
And as regards cachexia, it is certain, that 'scrofulous glands' often de- 
velop in persons who appear in all other respects in the best of health ; 
and further (if we may judge by the limitation of the morbid process), 
that if we admit their dependence on a pre-existing state of cachexia, 
that cachexia must in many cases be limited to a definite part or district 
of the organism. It is well known, however, that when a single gland 
has undergone scrofulous proliferation, there is a remarkable tendency for 
the morbid process to spread thence to other glands, in its immediate 
neighborhood, and thence again to others ; it seems in fact to spread from 
gland to gland, through the agency of some infective material, which the 
diseased organs evolve. It is well known also, that scrofulous enlarge- 
ment of the glands of the neck not unfrequently follows upon certain dis- 
eases affecting the throat, such as mumps, diphtheria, and scarlet fever. 
Now, basing his arguments upon such facts as these, Virchow maintains 
(and we think with reason) that scrofulous proliferation of lymphatic 
glands, like ordinary inflammatory hyperplasia of the same organs, is al- 
ways secondary to some peculiar process going on at the mucous surface, 
or other part, which is in direct relation with them by means of the lym- 
phatic vessels — that scrofulous disease of the glands of the neck is trace- 
able to some inflammatory condition of the throat, fauces, or contiguous 
parts ; of the bronchial and mediastinal glands, to pulmonary or bronchial 
inflammations ; and of the mesenteric and retro-peritoneal glands, to 
similar conditions of the alimentary canal. He considers that there may 
be. some specific quality or element in the primary inflammation, and a 
tendency in its products to undergo rapid decay similar to that which 
characterizes the morbid products of the diseased lymphatic glands ; but 
that generally they are not recognizable, from the fact that in this case 
the cells are mostly developed at a free mucous surface, and are speedily 
shed from it. But he considers, further, that there may be some special 
aptitude or weakness, congenital or acquired, in the lymphatic glands of 



LYMPH ADENOMA. 



81 



certain persons, or of certain parts of them, which makes their inflamma- 
tions, induced by indifferent causes, assume the scrofulous character. 

The affection now generally known as ' lymphadenoma,'' differs but little 
anatomically from the morbid conditions which have just been described. 
It is characterized like them by a simple overgrowth of lymphatic tissue — 
that is, by a development of cells, which essentially resemble ordinary leu- 
cocytes, in the meshes of a trabecular tissue like that of normal lymphatic 
glands. The cells here, as in healthy glands, are so abundant, that in an 
unprepared section, they conceal all other elements; but if they be removed 
by pencilling or washing, the fibrous matrix and vessels come into distinct 
view. The lymphatic glands in this affection, and other parts which be- 
come implicated, rapidly increase in bulk, acquire for the most part an 
opaque milky aspect, soften, and yield, like carcinoma, a milky juice. 
They are liable also to fatty and caseous degeneration, and to be the seat 
of hemorrhage. There are two ways in which lymphadenoma tends to 
produce important and characteristic results— the one by generalization, 
the other by modifying the quality of the blood. 

Lymphadenoma is generally distinguished, from both simple inflamma- 
tion and scrofulous proliferation, by the following important facts: — first, 
that the morbid process tends pretty rapidly to involve the lymphatic 
glands distributed throughout the organism ; and second, that there is a 
disposition to heterologous development of identical morbid gland-tissue in 
situations in which normal gland-tissue has no existence. In other words, 
lymphadenoma must be looked upon as a variety of malignant disease, in 
which the secondary as well as the primary growths assume the microscop- 
ical characters of lymphatic tissue. It should be remarked, however, — in 
the first place, that by lymphatic or adenoid tissue is not meant the whole 
complicated organism of lymphatic glands, but merely that comparatively 
simple arrangement of reticulated fibres and leucocytes, which is found in 
the solitary intestinal glands, and in the Malpighian bodies of the spleen ; 
and, secondly, that the recent investigations of several German physiolo- 
gists, and of Dr. Burdon Sanderson in this country, have shown that lym- 
phatic tissue is very abundantly distributed throughout the body (amongst 
other places in the subserous tissue, in the submucous layer of the intestine 
and along the bronchial tubes and the hepatic ducts) and that hence arises 
a possibility that, notwithstanding the diffusibility of lymphadenoma, its 
heterologousness and malignancy may, in the strict sense of these terms, 
only be apparent. Lymphadenoma not unfrequently affects the bronchial 
and mediastinal glands ; and it may extend thence, along the connective 
tissue which invests the bronchial tubes, into the substance of the lungs, or 
may invade the parietes of the heart, insinuating itself between its muscular 
fibres, without necessarily forming any distinct tumor. The mesenteric 
glands also are often chief seats of the disease ; which is then apt to trans- 
gress their limits, to involve the substance of the mesentery, and to creep 
thence into the intestinal walls, which consequently become thickened in 
all their layers, and probably at length present flat tubercular elevations on 
both the mucous and serous surfaces. The liver, spleen, and kidneys also 
are peculiarly liable to suffer. Here, as in the heart, the growth tends 
rather to infiltrate the tissues than to form defined and independent tumors. 
In the fresh condition, the affected tracts of these organs present an opaque 
milky aspect, which may be in striking contrast with that of the surround- 
' ing healthy parts ; and if they abut on the surface they probably form a 
slight convexity there. When however the contrast of color has been im- 
6 



82 



TUMORS. 



paired or lost by maceration, it is sometimes impossible by the naked eye 
alone to distinguish the healthy from the diseased parts. In the spleen the 
microscopical characters of the morbid growth are almost identical with 
those of the healthy gland-tissue; in the liver and kidneys, however, the 
growth infiltrates the texture of the organs, and separates their proper 
elements from one another. In the kidneys especially this may be well 
observed ; for the lymphoid growth spreads through the intertubular tissue 
of the organs, separating the still healthy tubes and Malpighian bodies from 
one another, until at length they appear to be sparsely distributed in a 
nearly homogeneous mass of adventitious cell-growth. 

The other special characteristic of lymphadenoma is its tendency to in- 
fluence the quality of the blood. Knowing as we now do that the lympha- 
tic glands and the spleen, and probably also lymphatic tissue, wherever it 
may be situated, are the laboratories in w 7 hich the corpuscular parts of the 
blood are manufactured, and further that they are the media through which, 
in chief measure, the elements and the products of local morbid processes 
are thrown into the system, we should naturally expect that anything 
which impairs or modifies their functions would soon lead to impairment or 
modification of the quality of the blood, and hence to various affections of 
the general organism. The influence of the morbid glands in lymphade- 
noma over the constitution of the blood is, however, quite special. Some 
years ago now, Dr. Hughes Bennett and Professor Yirchow discovered 
almost simultaneously that in certain cases of morbid enlargement of the 
lymphatic glands or spleen, the circulating blood was characterized by con- 
taining a comparatively small proportion of red corpuscles, and a compara- 
tively large number of leucocytes. These observations have since been 
confirmed and extended by many pathologists, and by Professor Yirchow 
himself. And it may now be regarded as established that, in the disease 
under consideration — lymphadenoma — the blood gets gradually and per- 
manently deteriorated in quality by the addition to it, from the diseased 
lymphatic glands, of the morbid leucocytes which they produce — leucocytes 
which microscopically differ little from those proper to the blood, but fail 
to undergo conversion into red corpuscles ; and that hence the red corpus- 
cles diminish in number, while the white corpuscles accumulate, until finally, 
in extreme cases, they outnumber them. This change in the blood is 
attended with increasing pallor of that fluid, which reveals itself by increas- 
ing pallor of the skin and mucous membranes ; and has obtained for the 
disease in which it occurs the name of leukcemia or leucocythcemia. 

Cases in which leucocythaemia is present may be divided into three 
classes : — in one the disease producing it is limited to the lymphatic glands ; 
in another it is splenic only ; and in a third both spleen and lymphatic 
glands are implicated. Yirchow distinguishes lymphatic from splenic 
leucocythaemia by the circumstance, that in the former the white corpuscles 
are generally smaller than normal white corpuscles, while they contain for 
the most part solitary and comparatively large nuclei ; whereas in the 
splenic form of the disease, the leucocytes more closely resemble those of 
the normal blood, being equally large with them, and generally containing 
two or more nuclei of small size, which become obvious under the influence 
of acetic acid. When the spleen and lymphatic glands are simultaneously 
affected, both varieties of leucocytes may be discovered mingled in the 
blood. Lymphadenoma may be present, however, without the co-existence 
of leucocythaemia. 

[When an enlargement of the spleen and of the glands exists without 



TUBERCLE AND GRANULOMA. 



83 



any increase in the number of the white blood-corpuscles, the condition is 
called pseudo-leuksemia, of which, as in the true form of the disease, there 
are three varieties. In the first variety, the glands are alone affected; in 
the second, the spleen ; and in the third, both glands and spleen.] 

h.— Tubercle and Granuloma. 

The latter term has been employed by Virchow to include the specific 
growths of syphilis, lupus, elephantiasis Grsecorum, and farcy, because 
anatomically they differ but little from ordinary granulation-tissue, and it 
is often difficult to decide from mere inspection whether such growths are 
tumors or mere inflammatory products. Tubercle he regards as a species 
of lymphoma ; and many pathologists are of the same opinion. It is by 
no means improbable that they are right, and certainly weighty arguments 
may be adduced in favor of their view. On the other hand, many good 
observers by no means admit the adenomatous nature of tubercle. And, 
therefore, since it is generally acknowledged to be closely allied to gum- 
mata and to the tubercles of farcy, it seem reasonable to classify it, at all 
events provisionally, with these latter affections. 

i. Tubercle From the time of Laennec down to within a very recent 

period, tubercle was regarded as a mere exudation or deposit from the 
blood, consisting in large measure no doubt of cells, but of cells which were 
degenerate from the beginning and never had any vitality ; and it was 
recognized as occurring in two forms — one, the gray granulations or miliary 
tubercles (hard, grayish, translucent bodies, varying from the size of a 
small pea downwards, and tending to become opaque, yellow, and soft or 
friable internally) ; the other, the so-called ; crude,' tubercles, which are 
generally of larger size, of a nearly uniform opaque buff color, and friable 
or cheese-like in consistence, but which were commonly believed to take 
their origin in the general caseous conversion of gray tubercles, and there- 
fore to represent a comparatively late stage of the tubercular process. It 
is now, however, generally admitted — that tubercle is no mere deposit, but 
on the contrary, equally with sarcoma and carcinoma, a living growth, 
consisting essentially of cells, but having, above all other growths, a ten- 
dency to undergo rapid degeneration and death, and especially that form 
of degeneration which is termed ' caseation ;' that the gray semi-trans- 
parent material which often forms the whole bulk of miliary granulations, 
and may often be recognized at the periphery of larger masses, is alone 
living and growing tubercle ; and that the yellow caseous substance which 
has frequently been taken for its essential part is merely effete and dead 
matter, often no doubt tubercular in its origin, but often also the detritus 
of quite other kinds of cell-growth. 

Gray granulations take their rise in the connective web of most organs 
and of many tissues, and, as will presently be shown, not improbably effect 
specially the lymphatic tissue distributed throughout the organism. They 
are common in serous membranes and in the pia mater, and it is probably 
here that their development may best be studied. If a minute tubercle 
from one of these situations be placed under the microscope, it will be 
found to consist mainly of an aggregation of cells, mostly of small size and 
of the embryonic character, of which those towards the centre will proba- 
bly even now be angular, withered, and opaque from granular fatty deposit. 
A close examination will reveal other facts : — the growth will be found 
almost certainly to have taken place in connection with some minute vessel, 



84 



TUMORS. 



probably to encircle it; and further, beyond the margins of what may 
perhaps be regarded as the actual growth, a zone of connective tissue will 
be recognized in which hypertrophy and profileration are commencing — 
the plasmatic cells being larger than those of the normal tissue, and in 
many instances containing in their interior broods of two, three, or more 
secondary cells. It would seem, therefore, that the morbid process com- 
mences with proliferation of the connective-tissue elements of the adventitia 
or outer wall of bloodvessels, that it gradually involves more and more of 
the neighboring connective tissue, and that as it spreads at the margins the 
central parts fall rapidly into decay. It follows that the chief microscopic 
elements of tubercle are — first, simply enlarged connective-tissue corpuscles 
(fusiform and stellate) ; second, these same cells containing two or more 
new cells within them; and third (and probably far most abundantly), 
small shrivelled granular embryonic corpuscles. But during the last few 
years it has been distinctly ascertained that, although neither peculiar to 
tubercle nor essential to it, certain cells presenting remarkable characters 
are commonly to be found, either in the centre of elementary tubercles, or 
distributed in the peripheral parts of agglomerated tubercles. These are 
large irregular branching bodies, termed 'giant cells,' of which each con- 
tains from twenty to forty distinct nuclei. Their source is not clearly 
determined. In some cases possibly they result from the fusion of smaller 
cells ; but M. Brodowsky has recently shown it to be probable that, at any 
rate, some of them are to be regarded as morbid modifications of protoplas- 
mic buds from the walls of vessels, which, under other circumstances, 
would have become vessels. It should be added, that new bloodvessels 
seem never to form in the tubercular process ; that no higher stage of 
development, in fact, than the mere over-production of new cells of a low 
grade of organization is ever attained ; and further, that the vessels around 
which tubercles form become at a very early period obstructed by the 
coagulation of fibrine, and the accumulation of leucocytes, in their interior. 
The inter-cellular substance of tubercle is, in the first instance, that of the 
particular form of connective tissue in which it originates ; it soon, how- 
ever, gets scanty and indistinctly fibrous or granular. Rindfleisch has 
described a reticulated connective tissue, in the meshes of which the cor- 
puscular elements are contained — an arrangement, in fact, almost identical 
with that which obtains in adenoid tissue, and which, if generally present, 
goes far to confirm the views of those who regard tubercle as an adenoid 
growth. It is extremely difficult, however, to satisfy one's self of the 
presence of any such fibrous stroma, and MM. Cornil and Ranvier dis- 
tinctly deny it. They admit that a kind of reticulum, probably of artificial 
production, may be recognized in sections which have been hardened with 
chromic acid or with alcohol ; but they assert that it never contains pro- 
toplasmic particles (as lymphatic stroma does) at the points where the 
fibres intersect, and moreover that in the unprepared tubercle it has no 
visible existence. 

But even if tubercular growths be not, like lymphadenomatous tumors, 
mere overgrowths or reproductions of modified lymphatic-gland structure, 
there can be no doubt at all that they are in very large proportion adventi- 
tious growths originating in lymphoid tissue. At all events, many physiolo- 
gists, and particularly Dr. Sanderson, have shown satisfactorily that adenoid 
tissue is far more generally distributed throughout the body than was for- 
merly suspected, and that it is especially abundant in all those parts in 
which tubercle is most frequently developed ; and indeed, as regards tuber- 



TUBERCLE. 



85 



cles produced experimentally, Dr. Sanderson seems to have clearly demon- 
strated their origin in hyperplasia of these normal lymphatic accumulations. 
"We need hardly quote, in favor of this doctrine, the fact of the frequent 
development of tubercle in the lymphatic tissue of the solitary and agminated 
glands of the intestines, and in that of the spleen and lymphatic glands. 
We will discuss two cases, however, which Dr. Sanderson has specially 
investigated, in the course of his experiments on the artificial production 
of tubercle. In the first place, he has shown that in the peritoneum, as 
indeed in all serous membranes, small masses of adenoid tissue are distri- 
buted abundantly, in some cases unconnected with vessels, but more com- 
monly adherent to their walls, or encircling them, or even investing whole 
groups of capillary vessels ; he has also shown that, in animals dead of 
acute peritonitis, all these masses have become soft, tumid, and enlarged ; 
and further that, when tuberculosis is in progress, it is in them and by the 
multiplication of their cells, rather than by that of connective-tissue cor- 
puscles, that miliary tubercles are gradually developed. Secondly, as regards 
the lung, it is now generally held that gray tubercles originate in the matrix 
of the organ, and not, as was formerly believed, within the air-cells ; and 
it is generally admitted, we believe, that the part which they chiefly affect 
is the connective tissue surrounding the bronchioles at the point at which 
these lose themselves in the air-cells, and that the growth of tubercle-cells 
gradually extends thence into the substance of the tissue, which separates 
the air-cells from one another, and limits each pulmonary lobule. Now, 
according to Dr. Sanderson, there always are normally, in the situation 
here indicated, masses of adenoid tissue, and the early stage of pulmonary 
tuberculosis consists in a kind of hyperplasia of such masses. 

The frequent connection between tubercle and adenoid tissue must be 
admitted. Nevertheless it is certain that, like lymphadenoma, tubercle does 
not take its origin exclusively in adenoid tissue. The general result, de- 
ducible from recent observations with respect to the genesis of tubercular 
products, seems to be that, like the products of inflammation, they are not 
derived from a single source — that they are not the results of specific hy- 
perplasia of connective-tissue corpuscles alone, as Virchow teaches, nor yet 
simply overgrowth of the lymphatic cells of adenoid tissue — but that they 
are probably derived, in varying proportions, from both of these sources, 
from the other cellular elements which happen to form part of the affected 
tissue, and even from immigrant leucocytes. 

The view here expressed has an important bearing on the question 
' what is and what is not to be regarded as tubercle ? ' — a question of the 
highest interest, in reference to the status of the morbid condition of lung 
commonly known as i pulmonary phthisis,' and to the nature of closely 
related, if not identical, morbid conditions of other organs. According to 
views generally accepted until within the last few years, the gray miliary 
tubercle and the yellow cheesy tubercle (of which both are common in the 
lungs, and the latter occasionally, by coalescence, infiltrates large tracts) 
were regarded as being, not so much varieties, as different stages of the 
same disease ; and it was held that, in the dead-house, all the intermediate 
conditions, by which the minutest miliary tubercles lead up to the most 
extensive caseous infiltration, can be readily recognized. At the present 
day, Virchow and many other distinguished pathologists deny this relation, 
and maintain that caseous disease, which comprises probably all the cases 
recognized clinically as pulmonary phthisis, is of pneumonic origin — the 
consequence of catarrhal or lobular pneumonia. The grounds of this 



86 



TUMORS. 



opinion are mainly, that in caseous infiltration of the lung, the presence of 
tubercular proliferation of the interstitial tissue is not a very obvious ana- 
tomical feature ; and that the great bulk of the morbid mass consists of 
degenerate epithelial cells accumulated in the air-cells and smallest bron- 
chial passages. Many important considerations, however, may be adduced 
in favor of the opposite view. It is a fully recognized fact that, even in 
undoubted examples of miliary tubercles, the proliferation of cells in the 
matrix of the pulmonary lobules, which constitutes their commencement, 
is soon attended with dense accumulation of cells, probably due to epithe- 
lial proliferation, within the pulmonary loculi. Now, unless we start with 
the assumption that tuberculosis consists in nothing else than proliferation 
of connective-tissue corpuscles, or of the elements of adenoid tissue, what 
right have we to assume that the protoplasmic bodies, which fill the air- 
cells, are specifically different from those which occupy the substance of 
the matrix? It is admitted that pus-cells may originate in epithelial as well 
as in other kinds of cells ; why should tubercle-cells have a more exclusive 
parentage? It is a recognized characteristic of tubercle that its specific 
cells very rapidly fall into degeneration ; but this is even more remarkable 
in the cells which fill the loculi, than in those which crowd the pulmonary 
matrix. Again, the caseous masses of pulmonary phthisis certainly do not 
occupy those parts of the lung, which either lobular or lobar pneumonia 
specially affects ; but they do occupy those situations (mainly the upper 
portions of the lungs) in which miliary tubercles generally originate, and 
are most advanced. And, lastly, caseous tubercles in the lungs are con- 
stantly associated with tubercular formations elsewhere in the body, and 
indeed in those very parts in which generalized miliary tubercles are spe- 
cially apt to manifest themselves. For many reasons, therefore, of which 
we have only indicated the more important, we are disposed to maintain 
the relationship between miliary tubercles and caseous infiltration, to regard 
them simply as varieties or different stages of the same disease, and to sup- 
port the claim of ' pulmonary phthisis' or 'caseous pneumonia,' to be called 
also 'tubercular phthisis.' 

The recent investigations of Dr. Klein 1 and Professor Charcot 2 are 
strongly confirmatory of the views here advocated. Dr. Klein shows that, 
in miliary tubercles of the human lung, ' the first changes take place in 
the alveoli and inter-alveolar septa ;' that, as regards the alveoli, the epi- 
thelial cells become swollen, granular, and detached, that they then pro- 
liferate, and that generally, either by their coalescence or by the dispro- 
portionate enlargement of one or more of them, each cavity becomes filled 
with a multinuclear lump of protoplasm or giant cell, which subsequently 
undergoes fibrillation, caseation, or other form of degenerative change ; 
and that, as regards the inter-alveolar septa, these thicken with the growth 
of a tissue containing branched and spindle-shaped cells and a few lym- 
phoid cells. He adds, that, at a somewhat later period, cords of adenoid 
tissue are formed upon the walls of the larger vessels in the vicinity of the 
tubercles. He further points out, in reference to tuberculosis of artificial 
production, that although the ultimate changes are identical with those 
just described, they take place in an inverse order — the development of 
the perivascular adenoid cords preceding the changes in the inter-alveolar 

1 1 On the Relation of the Lymphatic System to Tubercle.' Report of the Medi- 
cal Officer of the Privy Council. New Series, No. 3, 1874. 

2 ' Revue Mensuelle de Medecine et de Chirurgie,' 1877, p. 876. 



TUBERCLE. 



87 



septa and in the air-cells ; and he concludes that, in artificial tuberculosis, 
the process commences from the arteries and veins, in the idiopathic affec- 
tion from the pulmonary capillaries. Professor Charcot's observations are 
still more to the point, for he expressly shows that there is no essential, 
genetical, or structural difference between miliary tubercles of the lungs 
and so-called ' caseous pneumonia.' He points out, however, that in the 
latter variety of pulmonary phthisis the tubercular process commences in 
the parietes of the bronchioles where they lose themselves in the air-cells ; 
and that softening takes place here before any trace of inflammation is 
visible either in the epithelial lining of the tubes or in the pulmonary 
lobules connected with them ; and further, that when a caseous patch is 
examined, it presents a central degenerate area, and a marginal zone of 
embryonic cells, and scattered giant-cells, infiltrating the normal tissues of 
the lung. 

The quasi-malignant character of tubercle is generally admitted ; al- 
though the fact that it appears often to originate, almost simultaneously, 
in many points of one or more organs (in both lungs, for example), might 
seem to imply the existence, in some cases, of a widely-diffused tendency 
of organs to become tubercular, independently of specific infection. The 
proof of its malignant attributes lies, partly in that disposition to general 
diffusion which it shares with growths which are unquestionably malig- 
nant, and partly in the facts, that its local spread is due chiefly to the 
establishment of new foci of disease in clusters around the primary growths, 
and that the nearest lymphatic glands always becomes secondarily affected 
at an early period. It was considered by Laennec (and his view in a 
very slightly modified form has been advocated by Dittrich and Niemeyer) 
that a degenerate mass of tubercle — a caseous lymphatic gland, for exam- 
ple — is a common, if not the invariable, source of generalized tuberculosis 
— that the degenerate particles taken up by the blood become distributed 
by it, and then act as specific irritants to the parts which they infect. w 

The remarkable experiments, in reference to the production of tubercle 
by inoculation, first made by Villemin, and since repeated and extended 
by Wilson Fox, Sanderson, Cohnheim, and others, have a very interesting 
bearing on the points considered in the last paragraph. Guinea-pigs and 
rabbits were inoculated with tubercular matter ; and it was found that, 
after the lapse of some weeks, small indurated caseous nodules had become 
developed at the seat of operation, the next lymphatic glands had under- 
gone hyperplastic enlargement, and the lungs, liver, serous membranes, 
and some other organs presented a greater or less number of small, gray, 
translucent, hard bodies, which accurately resembled the miliary tubercles 
occurring in man ; and it was assumed that all these secondary formations 
were really tubercle, and that tubercular detritus taken up by the absorb- 
ents, and then distributed throughout the organism, had a specific influence 
in the production of tubercle. It was soon proved, however, that the in- 
oculation of other forms of growth, or of decomposing healthy tissue, or of 
the products of local inflammations excited by mere mechanical irritants, 
was quite as efficient in generating general tuberculosis, as was the inocu- 
lation of tubercular matter itself. And hence it became obvious, that the 
exciting cause of the tubercular development was, not the matter which 
was inserted or applied locally, but the products of the inflammatory pro- 
cess which this matter evoked. The experiments failed, therefore, to prove 
the inoculability of tubercle, but they prove that tubercle might be pro- 
duced locally by direct non-specific irritation, and that tubercle so engen- 



88 



TUMORS. 



dered had the capacity for becoming generalized. To a certain extent 
then, these experiments may seem to favor the views of Laennec and Nie- 
meyer, as to the infective quality of caseous matter. It is more in accor- 
dance, however, with what is now known of morbid proliferation, and of 
contagium, to assume that the infective element of tubercle is not effete 
and dead material, but rather living (even though degenerating) particles 
of protoplasm. 

The most common seats of tubercle are the lungs and the mucous mem- 
brane of the intestines. But tubercles are generally largely distributed 
throughout the bodies of those who die tuberculous : and we may enume- 
rate as their seats of election, after the lungs and bowels, the serous mem- 
branes, the spleen, the kidneys and liver, the brain and its membranes, 
the mucous surface of the genito-urinary organs, the supra-renal capsules 
and the bones, and of course the lymphatic glands. 

ii. Syphilitic gummata have a close anatomical affinity with tubercle, 
on the one hand, and with inflammatory products on the other. They re- 
semble granulation-tissue, in the general character and arrangement of 
their cellular structure, and in the facts — that they are provided with per- 
meable vessels, and that at an early period of their growth they are capa- 
ble of conversion into cicatricial tissue. They tend, however, like tuber- 
cles, to undergo early caseation and death ; and if their progress be not 
modified by medical treatment, this may be regarded as their normal ter- 
mination. It is in this latter condition that they are almost invariably 
found post mortem in the liver, testicles, and brain, bones, and other inter- 
nal organs. They then form opaque, buff-colored, toughish masses, im- 
bedded in dense connective or cicatricial tissue. They are especial com- 
mon in the skin and subcutaneous connective tissue, but here they generally 
undergo ulceration and leave indelible cicatrices. Excepting by their 
toughness, by the size which they attain, and by the paucity of their 
numbers, it would be exceedingly difficult to distinguish caseous gummata 
from tubercles in the same condition. In the brain and testicles especially 
the resemblance between gummata and tubercles is remarkably close. 

i Sarcomata. 

The term ' sarcoma' was formerly applied to all tumors which were 
supposed to have a fleshy character, and hence came to be used indiscri- 
minately, and to have no concise meaning. It is now, however, limited 
in its application to those growths which consist, not in their beginnings 
merely, but throughout the whole term of their existence, of embryonic 
tissue. Virchow regards them as belonging to the series of connective- 
tissue tumors which have already been described, and shows that the latter, 
especially when they undergo generalization, tend to get more or less ob- 
viously sarcomatous, that is, tend to become more and more exclusively 
cellular, and to lose more and more their several distinctive characters. 
Sarcoma differs structurally little, if at all, from simple inflammatory 
granulation-tissue ; both of them consist essentially of embryonic cells, 
which in the first instance are small, and round, and separated from one 
another by the least possible quantity of intercellular substance ; in both 
cases there is a tendency, as organization proceeds, for the cells to grow 
fusiform or spindle-shaped, while still retaining their embryonic charac- 
ters ; in both cases the anatomical and other features of the new-formed 



SARCOMA. 



89 



cells are modified, to some extent, according to the nature of the tissues 
in connection with which they arise ; and in both cases the growths be- 
come abundantly vascular from the development of the new vessels, the 
parietes of which are formed of cells, little if at all modified from those 
which constitute the general mass. They differ materially, however, in 
the fact, that inflammatory formations tend to subside or to form mere 
cicatricial tissue, while sarcomatous tumors maintain a continuous vitality 
of growth, present a wider range of variations from the primitive type of 
structure, and are in large proportion malignant. 

Many varieties of sarcoma may be described. If it affects a bone, or 
an osseous tumor, or is attended in its progress with osseous transformation, 
we have what may be termed an ' osteosarcoma? ; and if, under analo- 
gous growth associated with simple fatty or mucous gliomatous tissue, 
we have tumors which may be named respectively ' lipomatous sarcoma, 
' myxosarcoma' and 1 gliosarcoma.' Again, sarcomata may undergo 
fatty or calcareous degeneration, or mucous softening, and hence acquire 
special characters. The occurrence of degeneration, and especially of 
mucous softening, often leads to the formation of cysts ; and then arises 
that variety of sarcoma commonly known as 1 cystosarcoma.' 

Sarcomatous tumors are often, and perhaps best, classified according to 
the characters presented by the cells which predominate in them — the pre- 
sence of any of the modifications, which have been above indicated, then 
marking only subordinate divisions or varieties. There are at least four 
such species of sarcoma which we may briefly consider : namely (i.) round- 
cell sarcoma; (ii.) spindle-cell sarcoma; (iii.) large-cell sarcoma; and 
(iv.) melanoid sarcoma. 

i. Round-cell sarcoma. — In this species the structure of the growth 
approaches nearest to that of ordinary granulation-tissue — the cells being 
small, round, distinctly nucleated, and separated by little intercellular sub- 
stance. Such tumors are nearly homogeneous, but soft and pulpy in 
texture, grayish or white in hue, opaque or slightly translucent, and (if 
they have been removed some hours from the body) yield a milky juice. 
They are very vascular, often attain enormous dimensions, and are malig- 
nant in a very high degree. They originate almost indifferently in all 
parts of the organism; but especially perhaps in the skin and subcutaneous 
connective tissue, in glandular organs, particularly the breast and testicle, 
in bones and muscles. They comprise most of the tumors which were 
formerly called 4 medullary sarcoma' and ' encephaloid,' and many of those 
which were termed 'fungus haematodes.' 

ii. Spindle-cell sarcoma. — In this case the growth consists of cells which 
have become elongated and fusiform, or spindle-shaped, and hence present 
a higher grade of development than those of the round-cell sarcoma. The 
cells vary a good deal in size, and contain each from one to two or three 
nuclei. They are arranged side by side in bands or bundles, which take 
a curvilinear course and cross one another in various directions; so that, 
on examining a microscopic section, we see round or oval groups of appa- 
rently round or oval cells, surrounded by bands of fusiform cells — the former 
being simply cell-bundles which have been cut across more or less obliquely. 
Spindle-cell sarcomata are harder and denser than round-cell sarcomata, 
grayish or white, slightly translucent, and of a more or less distinctly fibrous 
or lobulated character. They yield but little juice. They have a tendency 



90 



TUMORS. 



to recur, and even to present malignant characters ; but their malignancy 
is far less pronounced than that of round-cell sarcomata, and they rarely 
reach the size which these latter attain. Spindle-cell sarcoma is synony- 
mous with ' fasciculated sarcoma,' and includes Paget's ' recurrent fibroid 
tumors.' 

iii. Large-cell sarcoma In some cases the cells of sarcomatous tumors 

attain unusually large dimensions. The most characteristic example is 
that furnished by Paget's 'myeloid tumors' of bone. These originate only 
in bones, destroy them extensively, and grow to a large size. They are 
made up to a considerable extent of embryonic cells, both of the round and 
spindle-shaped varieties ; but that which distinguishes them from all other 
forms of sarcoma is the presence of a greater or less abundance of large 
cells containing many nuclei. These cells, which are obviously derived 
from the many-nucleated cells of the healthy medulla, present much variety. 
They may measure as much as the hundredth part of an inch in diameter, 
and thus be objects distinguishable by the naked eye ; they may be round 
or oval, but generally are irregular, and present a more or less complex 
arrangement of buds or tails ; and they may contain any number of nuclei 
between two or three and two or three hundred. They consist of masses 
of protoplasm, unbounded by distinct cell-wall, and with the nuclei im- 
bedded in their substance. Although myeloid tumors have unlimited 
powers of local development, and even invade and grow along the veins, 
they are very rarely malignant in the true sense of that word. 

iv. Melanoid sarcoma — In this form of tumor the embryonic cells, 
which constitute it, are more or less loaded with minute pigment granules. 
The cells are round, oval, or fusiform — generally the last — and separated 
from one another by a small amount of intercellular substance. Each con- 
tains one or two distinct oval nuclei. The pigment granules are roundish 
or angular, and separately might pass for oily or cretaceous particles ; they 
are deposited chiefly in the extra-nuclear protoplasm, and sometimes in 
such abundance that the cell under the microscope appears black, and the 
nucleus is altogether concealed ; but they are found also in the substance 
of the nucleus. Melanoid sarcomatous tumors are generally soft, and pre- 
sent — if large, a mottled sepia-brown or black appearance ; if small, a more 
or less uniform black or brown hue. They take their origin almost in- 
variably in structures which normally are pigmented, such as the choroid 
coat of the eye and congenital pigmented nasvi ; and when they become 
generalized, the secondary growths repeat the pigmented character of the 
primary growth, thus furnishing a good example of the tendency, which 
secondary growths always have, to reproduce the specific characters of the 
parent tumor. Melanoid sarcomata are generally highly malignant. 

Closely related to the sarcomata, and by Cornil and Ranvier placed 
among them, is the growth termed by Virchow 'PsammomaJ which occurs 
solely in connection with the membranes of the brain and cord. It is 
vascular, soft, and friable, and chiefly characterized by an abundant de- 
velopment of concentric earthy concretions surrounded with capsules of 
flattened cells or scales. The type of these tumors is furnished by the 
choroid plexus. They rarely attain a large size, and probably never cause 
mischief unless they be large. 



CARCINOMA. 



91 



j Carcinomata, or Cancers. 

Cancerous tumors are considered by Virchow to be of a higher type 
than any which have hitherto been considered. He regards them, not as 
the mere hyperplastic condition of a single structural element, but as con- 
sisting of a combination of tissues, so arranged as to present some of the 
distinctive characters of an organ ; and he includes them, therefore, in his 
class of ' organoid tumors.' They are composed of a fibrous framework, 
or stroma, so arranged as to form a series of loculi, and of groups of cells 
which are contained in dense masses within them. The stroma consists 
for the most part of ordinary fibrous tissue and plasmatic cells, and carries 
and supports the arteries, veins, and capillaries, which are sometimes very 
abundant ; it may be extremely dense or comparatively lax, and varies 
much in quantity relatively to the size and number of the spaces which it 
invests. The loculi differ in size, and on casual examination seem to be 
round or oval, and unconnected with one another ; but as a rule they com- 
municate freely, and form a series of branching channels. The cells are 
said by Virchow, and by many others, to be of an epithelial character ; 
and they are so far epithelial, that they are developed from the surface of 
the loculi, are in absolute contact with one another, have no intervening 
cement, and are never traversed as granulation-tissue is by vessels. They 
vary greatly in size, and on the average are considerably larger than those 
of sarcomatous growths. They vary even more remarkably in form, and 
indeed their polymorphous character is often regarded as typical of their 
carcinomatous nature. They may be round or oval, or from mutual pres- 
sure polyhedral ; but more frequently they are of very irregular form, pre- 
senting convexities or concavities upon their surface, and projecting here 
and there into flattened, pointed, bulbous, or nondescript processes. They 
consist of masses of protoplasm, more or less granular and often fatty, and 
containing within them one or more nuclei, which are for the most part 
round or oval, of comparatively large size, and exceedingly well defined. 
Moreover, they not unfrequently become vacuolated, or hollowed out here 
and there into globular cavities, which are termed by Virchow ' physali- 
phores,' and are regarded by him as reproductive cavities. Cancer cells 
frequently have a close resemblance to the cells of the vesical epithelium. 
Cornil and Eanvier deny their truly epithelial character, mainly because 
as a rule they have no distinct cell-wall, and because, although in contact 
with one another, they generally do not cohere. 

The origin of cancers, like that of all tumors in fact, is very obscure. 
Rindfleisch, taking epithelial cancer as the type, considers that all forms 
of carcinoma originate in* the hyperplasia of epithelial structures; which, 
as they grow, eat their way, as it were, into the subjacent tissues, hollow- 
ing them out into irregular cylindrical cavities, which then constitute the 
characteristic loculi of cancer. This mode of development calls to mind 
that of tubular glandular organs and hairs in the fcetus. Cornil and Ran- 
vier, on the other hand, who expressly exclude epithelioma from true 
cancers, and consider cancer cells as being in no sense epithelial, conclude 
(mainly from their observations on the development of carcinoma in the 
bones and in the mammary gland) that the alveoli, within which the cells 
grow and multiply, begin in the plasmatic spaces or serous canaliculi, which 
are directly continuous with the lymphatic vessels, and that even when 
they attain their full size they maintain this connection : so that in a sense 
the alveoli of cancer may be regarded as the dilated origins of lymphatic 



92 



TUMORS. 



vessels. To this connection, moreover, they attribute the peculiarly 
malignant character of all forms of carcinoma. Under any circumstances, 
however, the early stages of cancer are generally marked by the formation 
of embryonic tissue — of cells, therefore, differing little from those which 
are found in inflammatory processes and in sarcomatous growths. But 
soon differentiation takes place, and the specific character of the growth is 
revealed by the conversion of some of these cells into the fibrous tissue of 
the stroma, and of others of them into the epithelium-like cells of the 
loculi. There is good reason, nevertheless, for considering that the matrix 
in many cases, and in some perhaps almost exclusively, consists of the 
normal fibrous elements of the part affected, which have simply under- 
gone some degree of thickening and overgrowth ; just as in other cases, 
where glandular organs are involved, their follicles and ducts may be 
stimulated to unwonted development, and so form prominent objects in the 
field of the microscope, without necessarily constituting any essential part 
of the specific growth. 

Like other adventitious growths, but in a greater degree than most of 
them, carcinoma is liable to undergo degenerative changes : these involve 
principally the cellular elements, and are sometimes so uniform in their 
occurrence as to give a special character to the case in which they prevail. 
Fatty degeneration of cells is the most common ; but we meet also with 
caseous degeneration, calcareous deposit, and mucous softening ; and not 
unfrequently extravasation of blood takes place, owing to the rupture of the 
morbid capillary vessels. 

All kinds of carcinoma are malignant — the most malignant being the 
soft or encephaloid form, with its pigmentary and other varieties ; the least 
malignant being epithelial cancer, which speedily involves the neighboring 
lymphatic glands, but is very rarely reproduced in other parts of the 
system. 

The chief varieties of carcinoma are (i.) Scirrhus or hard cancer; (ii.) 
Encephaloid or soft cancer; (iii.) Colloid or mucous cancer; (iv.) Epi- 
thelioma or epithelial cancer ; and (v.) Adenoid or tubular cancer. 

i. Scirrhus in its typical form, is known especially by its hardness and 
slowness of growth. It creaks on section, and its cut surface presents a 
white or grayish, glistening, fibrous character, and yields a little milky 
juice on scraping. Its density and hardness are due to the great abundance 
and thickness of its fibrous matrix, and to the comparatively small size and 
number of its cell-containing loculi. The cells, however (which consti- 
tute the essential element of the milky juice), present the ordinary charac- 
ters of cancer-cells. Scirrhous tumors rarely if ever undergo complete 
cure ; yet it is certain, not only that they are of slow growth, but that their 
progress is specially apt to be attended with the degeneration (chiefly fatty 
or caseous), and the subsequent disintegration and removal of the cells of 
considerable tracts, and the consequent disappearance from such parts of 
everything except the fibrous stroma. Scirrhus is equally characterized by 
the slowness with which it obviously involves the neighboring lymphatic 
glands, and becomes generalized. It invariably, however, sooner or later 
manifests the infectious qualities which belong to it. 

ii. Encephaloid cancer is very soft in texture and rapid in growth, 
yields a very abundant milky juice, presents a tolerably uniform opaque 
white sectional surface, which, however, may be variously studded with 



CARCINOMA. 



93 



patches of congestion or hemorrhage, of fatty or caseous degeneration, or 
even of pigmentary deposition. Its extreme softness is due to the fact 
that the fibrous stroma forms a very small proportion of the whole mass, 
while the cells are relatively very abundant. The alveoli differ in size, 
but are generally comparatively large, and their walls exceedingly delicate ; 
indeed, it is often difficult to recognize the latter at all, unless the cells be 
first removed by washing or pencilling. In encephaloid cancer, the sec- 
ondary involvement of the nearest lymphatic glands, and of the general 
organism, takes place very speedily. 

Several well-marked varieties of encephaloid cancer are met with, two 
or three of which may be here enumerated. These are, — first, erectile or 
hcematoid carcinoma, in which the vessels (always abundant in encepha- 
loid) are extraordinarily developed and tend to frequent rupture ; second, 
the variety which Cornil and Ranvier term ' pultaceous carcinoma,' in 
which the alveoli are thicker-walled than in most forms of encephaloid, so 
large that they can easily be recognized by the naked eye, and from which 
the contents readily escape as a thick pulpy juice ; third, lipomatous carci- 
noma, wherein the cancer-cells even from their infancy are loaded with oil, 
and in the adult state present so general and large an amount of it that, both 
to the naked eye and under the microscope, the tumor has (at first sight) 
a considerable resemblance to ordinary fat ; fourth, melanotic carcinoma, in 
which, as in the corresponding form of sarcoma, the cells are pigmented. 

iii. Colloid cancer has a very close resemblance to myxoma. In both 
cases the tumors are more or less transparent, and gelatinous in consistence, 
and in both yield from the cut surface an abundant juice, which is trans- 
parent, glairy, and characterized by containing mucine. The fundamental 
anatomical distinction between them is this, — that, whereas in myxoma 
the framework of the tumor consists of plasmatic cells, the mucous fluid 
and vessels occupying the interstices between them ; in colloid carcinoma, 
the mucus arises in the degeneration of the essential cells of the growth, 
the general solidity of the tumor being due to the fibrous stroma, which 
forms the walls of the alveoli. In colloid cancer the alveolar structure is 
extremely well-marked, and on this account colloid has often been termed 
4 alveolar cancer.' The alveoli are so large as to be easily visible to the 
naked eye ; they are round or oval on section; and when the growth forms 
a projecting mass on a serous surface, their aggregation presents the appear- 
ance of an accumulation of small bubbles of air in a viscid fluid. They com- 
municate freely with one another. Their walls are mostly extremely thin 
and delicate, displaying a fibrillated structure with an indistinct develop- 
ment of fusiform cells, which may themselves present indications of fatty 
or colloid degeneration. The glairy contents of the alveoli vary — from the 
consistence of white of egg up to that of pretty firm glue, from pure white 
to a more or less deep yellowish, brownish, or reddish hue, and from per- 
fect transparency to tolerably complete opacity. Microscopically, cancer- 
cells can always be recognized. The smaller alveoli of the newly-devel- 
oped parts are probably full of well-defined cells, of which some already 
contain globules of mucus. As, however, the growth gets older and the 
alveoli larger, the cells undergo more and more complete mucous degenera- 
tion, swell up, and presently disintegrate ; and thus in many cases the 
alveoli get distended with mucus, presenting a certain amount of granular 
matter, mostly arranged in irregularly concentric circles, with here and 
there perhaps the ghost of a huge dropsical cell. In addition to the mucous 



94 



TUMORS, 
i 



conversion, which is the especial feature of colloid cancer, a certain amount 
of fatty degeneration is common. Calcareous deposition also is not unfre- 
quent. 

Although colloid cancer is certainly malignant, and affects lymphatic 
glands, and occasionally becomes generalized, it is specially characterized 
by a tendency to spread in area, and to implicate the tissues immediately 
subjacent to that area. Thus, when arising in the peritoneum, it soon dif- 
fuses itself over the greater part of that membrane, and also soon involves, 
in many situations, the whole thickness of the stomachal or intestinal walls. 
It shows also (though it is not peculiar in this respect) an obvious prone- 
ness to spread along the lines of the lymphatic canals and capillaries. 

iv. Epithelioma, or cancroid, is a very characteristic form of growth, 
originating, but not quite exclusively, in epithelial tissue, and characterized 
by a very abundant formation of epithelium in cavities or loculi of consider- 
able size, which, as in other forms of carcinoma, communicate more or less 
freely with one another. 

The commonest form of epithelioma is that which arises in the skin, and 
those mucous surfaces which are in relation with the external orifices, 
namely, those of the lips, tongue, oesophagus, anus, vagina, and uterus. 
It forms a tumor which varies in size, soon ulcerates, and on section pre- 
sents (owing partly to the fact that the tissues which it invades are not 
yet wholly destroyed by it) a more or less variegated character; it is friable 
in texture, somewhat granular, and yields on pressure, not a juice, but 
rather an opaque, whitish, granular pulp. The stroma of the growth con- 
sists of fibrous or of embryonic tissue, including vessels, and more or less 
abundant traces of the original healthy structures. The pulp which exudes, 
and the contents of the loculi, consist solely of cells in different stages of 
development. These are distinctly nucleated, modified in shape by mutual 
pressure, and for the most part large and strikingly epithelial in character. 
The younger cells are in relation with the stroma, and occupy therefore 
while in situ the periphery of each cell-mass ; the others are arranged in 
a more or less stratified or confused manner within. But we find addi- 
tionally, in the latter situation, knots or nests or involucra of cells, the 
presence of which is almost conclusive as to the nature of the growth. 
These consist of large flat cells, arranged in concentric circles around a 
group of cells or even a single cell, of smaller size, of plumper form, thick- 
walled, and containing a nucleus, together with perhaps some mucous or 
colloid material, or a few small fat globules. At first sight, these nests 
look not unlike transverse sections of cutaneous papillae, but they obviously 
differ from them in the fact that their centres are made up simply of cells, 
and not of stroma containing vessels. . 

As regards the development of epithelioma, there is little doubt that 
when it occurs at epithelial surfaces, it commences with hyperplasia of the 
deeper-seated embryonic ceils of the epithelium : in the skin, therefore, 
with hyperplasia of the cells of the rete mucosum and of the sebaceous and 
sudoriparous glands; in the mucous surfaces, with hyperplasia of the cor- 
responding cells of their epithelium, and of the glandular crypts. These 
multiply, become modified in form and arrangement, distend the cavities 
or depressions in which they lie, and send thence into the immediately 
surrounding tissues bud-like processes. The latter increase in number and 
size, and thus gradually invade and destroy the neighboring textures. 
Eindfleisch quotes an observation and reproduces a drawing of Koster's, 



ATROPHY AND DEGENERATION. 



95 



which seem to show that the extension of epithelioma is due to the involv- 
ment of the lymphatic networks — that the budding or sprouting epithelial 
processes above adverted to, instead of forming indiscriminately, penetrate 
the capillary lymphatics, run along them, and distend them. There is 
probably some truth in this view ; and, if so, it assimilates the local spread 
of epithelioma with that of colloid cancer, and especially with that of scir- 
rhous and encephaloid cancer, as described by Cornil and Ranvier. 

Epithelial cancer is undoubtedly the least malignant of all the varieties 
of carcinoma, for it is the only cancer which admits of being removed in 
its early stage with the tolerable certainty that it will not recur ; and 
although it soon involves neighboring lymphatic glands, it rarely manifests 
itself secondarily in other internal organs. 

v. Adenoid or tubular cancer, otherwise termed 4 columnar,' or * cylin- 
drical epithelioma,' is a rare affection, said generally to originate on some 
mucous surface, and to involve secondarily lymphatic glands and other 
organs. It occasionally, however, arises primarily in the liver or other 
parenchymatous organs. It forms tumors of various sizes, which have a 
close general resemblance to those of encephaloid cancer. They are highly 
vascular, soft, and yield an abundant milky juice. Microscopically, they 
are seen to consist of a system of tubules irregularly arranged, and separated 
only by a very small quantity of fibrous stroma; and bear a striking resem- 
blance to sections of the cortical substance of the kidney deprived of mal- 
pighian bodies. The tubules are generally cylindrical, of tolerably uniform 
size, and lined with a layer (usually single) of spheroidal or columnar epi- 
thelium. They present, for the most part, a distinct central cavity or 
canal. 1 This form of carcinoma is highly malignant. 

B. Atrophy, Degeneration, and Necrosis. 

1. Atrophy arid Degeneration. 

The term 'atrophy' means strictly mere diminution in the bulk of tissues 
from deficient nourishment. The term ' degeneration,' on the other hand, 
implies degradation of tissue — in other words, a qualitative rather than a 
quantitative change. A part which suffers atrophy simply wastes, while 
one which undergoes degeneration often presents an actual increase in bulk. 
Yet, although atrophy and. degeneration imply, so to speak, different lines 
of decay, these conditions are so constantly associated that, in a practical 
sense, they scarcely admit of separation. 

When degeneration is in progress, we find that the elementary constitu- 
tion of the parts involved gradually becomes confused and destroyed, and 
that accompanying this process fat, pigment, or other matters, which 
normally have no visible existence in them, are deposited in a globular or 
granular form. Whence do these matters come? Are they simply due to 
the decomposition of the highly organized material which has undergone 
degeneration, and to the precipitation of its more insoluble constituents ; or 
do the decaying tissues attract them to themselves from the blood or extra- 
vascular nutrient fluid? There can be no doubt that both of these pro- 
cesses take place ; and that, although they are distinct and not unfrequently 

1 See Dr. Greenfield's account of a case of this disease in vol. xxv. of the ' Path. 
Trans.' 



ATROPHY, DEGENERATION, AND NECROSIS. 



dissociated, they generally concur. In most cases, where degenerative 
products are visible, they are due partly to simple precipitation, partly to 
infiltration. 

It will thus be understood that degeneration, in its widest sense, involves 
three processes which are essentially distinct from one another : — namely, 
first, simple atrophy or wasting of tissues ; second, degeneration proper, 
or the decomposition of tissue ; and, third, the deposition in the affected 
parts of insoluble matters derived from without ; and that these processes 
are generally associated, although in very various proportions. It should 
be added, that the visible products of degeneration (according to the 
nature of which different names are given to the various degenerative pro- 
cesses) are only the more insoluble products of these processes ; that other 
effete or degraded matters are produced simultaneously, which are probably 
just as important, although more difficult to recognize, partly on account 
of their solubility, partly because they assume no crystalline, molecular, or 
other visible form. We shall discuss the generally-recognized varieties of 
degeneration seriatim . 

a. Cloudy swelling When cells are exposed to the direct influence of 

certain poisonous substances, or when they soak in the dropsical or inflam- 
matory fluids which escape from the blood, they often get distended from 
imbibition, and at the same time their protoplasm assumes a very finely 
granular condition. The same changes, according to Cornil and Ranvier, 
take place in the nuclei and nucleoli. Virchow regarded them as the 
result of nutritive irritation. But they are now generally admitted to be 
of a degenerative nature, or at all events passive, and in many cases a first 
step towards fatty degeneration. The granules, however, are not fatty but 
albuminous, and readily dissolve in acetic acid. Cloudy swelling is well 
shown by the hepatic cells, in cases of acute atrophy of the liver. 

b. Mucous and colloid degeneration In many cases cells, and' in 

some instances intercellular substances, undergo softening and conversion 
into matters which are known as ' mucus' and 4 colloid.' These may form 
a thin glairy fluid, or present all degress of viscidity between this and a 
thick jelly ; and may be transparent and colorless, or of different tints of 
yellow, brown, or red. They have, therefore, a very close resemblance to 
one another ; and, indeed, are not always easy to distinguish. They differ 
chemically in the fact that mucus contains mucine in solution — a substance 
which is precipitated by acetic acid ; w r hile the specific element of colloid 
is an albuminous substance which is not affected by this reagent. 

Mucous degeneration sometimes involves the intercellular parts of tissues, 
sometimes the cellular elements. Of the former case, we have examples 
in the mucous softening, which takes place in the matrix of enchondro- 
mata and of the cartilages of elderly persons, and perhaps also in myxo- 
matous tumors. The latter case is exemplified in the formation of globules 
of mucus within the cells of mucous membranes, the consequent distension 
of the cells and their final deliquescence. Mucous degeneration is common 
in the cells of synovial and mucous surfaces ; it is a characteristic feature of 
the progress of colloid cancer ; and it is of not unfrequent occurrence in 
other morbid growths — leading to the formation of cysts. 

Colloid matter is most frequently met with in the cysts of the thyroid 
body, and in small renal cysts ; and, like mucus, generally arises within 
cells, which it presently fills and destroys. In the cases just referred to, 



FATTY DEGENERATION. 



97 



it forms rounded jelly- or glue-like masses filling the cavities, and contain- 
ing imbedded in them the remains of the cells which gave them origin. 
It seems probable that the glassy transformation of voluntary muscles in 
typhoid fever, described by Zenker — and which is marked by a peculiar 
waxy lustre, the disappearance of the normal markings, and a tendency to 
crack transversely — is really an example of colloid degeneration. Further 
there is reason to believe that many so-called ' fibrinous' crests of the uri- 
nary tubules are rather colloid matter than fibrine. 

c. Lardaceous Degeneration, known also as ' waxy,' ' bacony,' 4 albumi- 
noid,' 'amyloid,' and 'scrofulous' degeneration has (as the many names 
which have been applied to it testify) long been recognized, and presents 
many very remarkable characteristics. It occurs almost exclusively in 
cases of tertiary syphilis, chronic phthisis, and long-continued suppuration 
especially in connection with bone-disease ; and, indeed, since prolonged 
suppuration is constantly associated with both the later stages of syphilis 
and chronic phthisis, there is some reason to regard the lardaceous change 
as the consequence essentially of suppuration. It affects mainly the liver, 
spleen, and kidneys ; which increase slowly to many times their original 
bulk, grow dense and homogeneous in texture and doughy in consistence, 
and present when cut a pale brownish tint, with a slight degree of trans- 
lucency and a peculiar waxy lustre. Microscopically, the change is found 
to be due to the infiltration of the walls of capillary and other small vessels, 
of the walls of ducts, and of the substance of cells, with a transparent, 
colorless refractive material ; which by its presence obliterates all their struc- 
tural characteristics, gives them a jelly-like or vitreous aspect, and con- 
verts the vascular and duct walls into thick homogeneous hollow cylinders, 
and the cells, with their nuclei, into amorphous masses, with a tendency 
to irregular fracture. The microscopical appearances of parts which have 
undergone lardaceous infiltration are not altogether unlike those displayed 
by* structures which are the seat of mucous or colloid change ; but larda- 
ceous matter is tougher and more consistent than mucous and colloid gene- 
rally are; it invades structures which these latter never affect, and more- 
over never leads to the deliquescence and utter destruction of tissues. The 
chemical characteristics of lardaceous matter are of considerable interest. 
Virchow, some years ago, finding, as he thought, that on the addition of 
sulphuric acid and iodine it assumed a blue tint, concluded that it was 
identical with the cellulose of plants, which under the influence of the 
same reagents becomes first converted into starch and then blue ; and hence 
he gave it the name of ' amyloid matter' — a name by which it is still largely 
known, although the theory which gave it origin is now only matter of 
history. It has been conclusively shown, indeed, that lardaceous matter 
has no sort of chemical relation with starch or cellulose, and that the addi- 
tion of sulphuric acid and iodine produces a bluish tint only in consequence 
of the precipitation of the iodine in a molecular form. Lardaceous matter, 
in fact, is a modification of albumen, with a deficiency of potash and phos- 
phoric acid, but with an excess of soda, hydrochloric acid, and especially 
cholesterine ; and it is easily recognized by its rapid absorption of iodine, 
even when this is applied in the form of a very weak solution, and its 
consequent acquisition of a peculiar and very characteristic reddish brown 
or mahogany tint. Dr. Dickenson has pointed out, as an equally valuable 
test, the readiness with which it gets stained blue by solution of sulphate 
of indigo. 
7 



98 



ATROPHY, DEGENERATION, AND NECROSIS. 



Lardaceous degeneration of organs, unless it becomes extreme, does not 
necessarily impair their functional activity.. Its effects in this direction 
only show themselves late in the progress of the disease, and are then 
probably due in great measure to pressure and other simple mechanical 
causes. 

Although occurring most frequently and obviously in the organs which 
have been named, lardaceous infiltration occurs also in other parts of the 
organism. Thus, it is not uncommon in the villi of the intestine and the 
mesenteric glands ; and the so-called ' corpora amylacea' of the nervous 
centres not only have microscopic characters resembling those of some 
forms of starch, but present the same chemical reactions as lardaceous 
matter occurring in other organs. 

d. Fatty Degeneration. — Three different conditions are not unfrequently 
included in this term: namely, first, the overgrowth of fat-tissue; second, 
the superabundant storage of oil in cells (other than fat-cells) which are 
apt to contain normally a greater or lesser quantity of oil ; and, third, the 
actual degeneration or decay of tissue attended with the appearance of 
molecules of oil in its substance. It is obvious that the first of these con- 
ditions is not a degeneration in any sense of the word. No doubt in many 
cases, as when it affects the heart, it impairs functional activity, but it 
impairs it by its mechanical influence only. Again, the second condition 
cannot properly be regarded as a degeneration. It is observed most char- 
acteristically in the so-called ' fatty degeneration' of the liver, where the 
organ increases in size, gets paler and softer than natural, and greasy, and 
is found under the microscope to have its constituent cells distended with 
accumulated oil-drops. But under normal circumstances the liver-cells 
contain a variable amount of fat. The presence of fat in them, therefore, 
is no sign that they are degenerate ; and moreover the excessive accumu- 
lation of fat in them does not lead to their destruction, nor does it (according 
to our experience) affect injuriously the performance of the hepatic func- 
tions. The third of the above conditions is that which alone merits the 
name of fatty degeneration. 

Fatty degeneration commences almost invariably in cells or other forms 
of protoplasm, which get studded with minute refractive molecules, and at 
the same time increase in bulk. These molecules are supposed to be de- 
rived mainly, if not exclusively, from the degradation or decomposition of 
the protoplasmic matter itself, and are at first few in number and small in 
size, and chiefly collected immediately around the nucleus. Gradually 
they increase in number and size, concealing the nucleus and distending 
the cell; which then acquires a round or oval figure, and appears by trans- 
mitted light as an opaque black granular mass, constituting what is gene- 
rally known as a ' granule-cell,' and has been sometimes termed an 'inflam- 
matory corpuscle.' The last stage is represented by the further enlargement 
of the cell, its rarefaction, and final deliquescence, with the setting free of 
the fat-granules which had been imbedded in it. In the later phases of 
fatty degeneration, when the cells are in great measure destroyed, and the 
oily matter is diffused throughout the tissues, cholesterine, which had 
doubtless been suspended in the oily molecules, separates from them, and 
appears amongst them in the characteristic form of incomplete rhomboidal 
plates ; and the whole tissue gets confused, softened, and reduced to an 
opaque yellowish-white pulp, or ' detritus.' 

The process above described is common in nearly all vital tissues. Pus 



PIGMENTARY DEGENERATION. 



99 



globules, epithelial cells, connective-tissue corpuscles are all apt in the 
course of inflammatory processes, to become granule-cells. Cartilage-cells 
undergo similar changes; and the stellate corpuscles of the cornea, and 
those of the inner coat of arteries are equally liable to be the seat of fatty 
deposition. Fatty degeneration of muscular tissue is of much interest. It 
occurs as a normal process in the involution of the muscular walls of the 
uterus after parturition ; it may often be detected in the hypertrophied 
muscular fibres of the walls of the stomach and intestines, when carcinoma 
or other such growths affect these organs ; and it is occasionally present 
in the voluntary muscles. But it is chiefly met with in the muscular fibres 
of the heart, and has indeed been principally studied in connection with 
this organ. It commences here with the appearance of fatty granules in 
the corpuscles which stud the substances of the fibres, and in the immediate 
vicinity of their poles ; but gradually they get more general in their dis- 
tribution, the fibres progressively losing their characteristic markings, and 
after a while becoming, like granule-cells, mere accumulations of granular 
matter. Fatty degeneration is often remarkably well seen in the cells of 
carcinoma, and many other kinds of morbid growths. 

The term ' caseation' is applied to that condition in which tubercles, 
syphilitic growths, carcinoma, and collections of pus acquire the appearance 
and consistence of some forms of cheese. It is essentially fatty degenera- 
tion ; but it is fatty degeneration in which there is a deficiency of moisture, 
in which the degenerate cells shrivel up instead of expanding and under- 
going solution, and in which the diseased mass becomes dry and friable 
instead of pulpy or fluid. It was formerly supposed to be distinctive of 
tubercle. 

e. Pigmentary Degeneration The deposition of pigmentary matter is 

not, any more than that of oil, necessarily a pathological process ; nor, even 
when pathological, is it to be regarded as necessarily an evidence of de- 
generation. All pigment, originating within the body, appears to be de- 
rived from the hasmatine or red coloring-matter of the blood r or from the 
coloring matter of the bile, which is itself a derivative of haematine. In 
either case, it may be simply diffused in a fluid condition among the tissues r 
or it may be deposited in the form of granules or small solid masses,, or it 
may assume a crystalline shape. And in either case, again, it may present 
various modifications of color; of which red, yellow, brown, and black may 
be taken as the types. The various stages of pigmentation may be ob- 
served superficially in the progress of a subcutaneous bruise; but to follow 
them thoroughly, it is necessary to investigate the changes which clots, 
and the tissues in which they are imbedded, present at different periods 
after extravasation. The blood-corpuscles soon lose their coloring matter, 
which speedily diffuses itself through the surrounding tissues, staining them, 
and more especially their protoplasmic particles, of a more or less bright 
yellow color. From this, ere long, granular pigment, of a yellow, brown, 
or black tint, is precipitated amongst the tissues, and in the clot itself; 
and, probably, at the same time, small refractive nodulated masses of a 
deep orange or pale red hue make their appearance. Lastly, small thick 
rhomboidal crystals, of a deep ruby color, are produced, which are gene- 
rally termed ' hsematoidin' crystals. The final color which the granular 
form of pigment assumes is either brown or black; and this, together with 
hrematoidin crystals, which are unalterable, is the permanent indication of 
the previous existence of extra vasated blood. A nearly similar series of 



100 ATROPHY, DEGENERATION, AND NECROSIS. 



changes may be observed in the liver, in cases where the escape of bile is 
prevented; namely, first, a general staining of the tissues, then a granular 
pigmentary deposit, and occasionally a more or less abundant formation of 
haematoidin crystals scarcely if at all different from those which are obtained 
from blood. It should be added that, according to Stadeler, bili-rubiri 
differs from haematoidin only in containing two more atoms of carbon ; and 
that the various modifications of color which bile undergoes by keeping 
are due to the development of substances which differ from bili-rubin only 
in possessing larger quantities of water, relatively to carbon and nitrogen. 

The pathological precipitation of brown or black pigment in a granular 
form is well seen, in the cells of the rete mucosum in Addison's disease, 
and in the brown discoloration which often succeeds various forms of skin 
disease and cutaneous inflammations — the results of chemical or other irri- 
tant applications; in the cells of melanoid carcinoma and sarcoma; and 
we might perhaps add, in the cells of the testis and of the gray matter of 
the brain, during the later periods of life. The deposition of yellow, red, 
and brown pigmentary granules, and of haematoidin crystals, is, as before 
stated, a common result of the extravasation of blood ; accordingly these 
matters are found in corpora lutea, in the neighborhood of apoplectic effu- 
sions, and in the parietes, in the interior, and in the vicinity of small vessels 
obstructed by clots or otherwise diseased. In certain cases of malarial 
fever, in which the spleen is seriously affected, black pigment-masses are 
formed in that organ through decomposition of blood-corpuscles, and are 
carried thence by the circulating blood, and deposited in the capillary 
vessels of other parts of the system. Black pigment, also derived from 
the blood, is frequently met with in the tissues of the lungs and bronchial 
glands. In reference to this latter case, however, we must not forget that 
inhaled carbonaceous matter gets absorbed by the epithelial cells of the 
bronchial tubes ; and that hence, just in the same way as pigments, arti- 
ficially introduced by tattooing, find their way along the lymphatics, so 
carbonaceous matter may be absorbed at the mucous surface of the bronchial 
tubes, and thence conveyed to the bronchial glands. Nevertheless, the 
black pigment found in them is doubtless, in nearly all cases, chiefly of 
blood origin. 

f. Uratic Degeneration This occurs only in gout. It is characterized 

by the appearance of needle-like crystals of urate of soda in the substance 
of articular cartilages, in the periosteum, synovial membranes, and tendons. 
They are observed mainly in connection with the protoplasm of the cells, 
are often irregular in their arrangement, but are very apt to form opaque 
densely-arranged star-like clusters. 

g. Calcareous Degeneration. — This consists in the deposition of a com- 
bination of carbonate and phosphate of lime in some previously existing 
albuminoid matrix, with which it combines to form minute granules and 
spherules. These increase in size by concentric additions to their surface, 
.and presently coalesce into botryoidal masses — the general form and ar- 
rangement of which are determined by the peculiarities of the tissue in 
which the process is going on. The precipitation of calcareous matter 
takes place almost exclusively in the intercellular substance ; which first 
appears dusted with minute granules, and then, as these multiply, becomes 
black and opaque to transmitted light. Later on, the enlarging granules 
run together, the blackness and opacity disappear, and the calcified tissue 



NECROSIS, OB, GANGRENE. 



101 



gets refractive and transparent. The cellular elements frequently remain 
intact, or nearly so, during this process ; and if they be stellate, and numer- 
ous, the result is the formation of a mass having a close resemblance to 
true bone. Calcareous granules have a superficial likeness to globules of 
oil ; but may be distinguished from them by their ready solubility (with 
the giving off of bubbles of carbonic acid gas) in hydrochloric and other 
acids, and if they be round by displaying a cross when examined by polar- 
ized light. Rindfleisch supposes, that the pathological deposition of calca- 
reous matter, which in the blood is rendered soluble by the presence of 
carbonic acid, takes place primary at the periphery of cell- districts ; and 
that it is due to the difficulty of reabsorption of nutrient matters which 
have found their way thither. This difficulty favors the separation of 
their more diffusible from their less diffusible constituents, and thus the 
removal of the dissolved carbonic acid, and the precipitation of the cal- 
careous matters which the carbonic acid had rendered soluble. This ex- 
planation accords very well with Mr. Rainey's views on the formation of 
shells and bone. 

Calcareous precipitation is very common. It occurs in the internal 
coat of arteries, and in the whole thickness of the walls of minute vessels 
in tendon and cartilage, and even in the substance of skin. It is especially 
apt to take place in inflammatory and other adventitious products. Thus, 
we find plates of calcareous matter (often assuming the characters of bone) 
in old false membranes of the pleurae and pericardium, in the lining of 
cysts, and in the choroid coat of the eye. And, indeed, most degenerative 
products — such as cheesy tubercles, inspissated pus and old clots — when 
they hate lost their moisture, and their more soluble or diffusible constit- 
uents, become its seat, and, first assuming a mortary condition, finally 
shrink into calcareous lumps. But, although earthy matter is deposited 
mainly in the tissues between cells, it is occasionally found in the interior 
of cells, and especially in those of unstriped muscle. It is thus that the 
smaller arteries are sometimes converted into rigid cylinders, and large 
portions of uterine muscular tumors into calcareous masses. 

2. Necrosis, or Gangrene. 

Several of the degenerations just considered end, as we have pointed 
out, in the disintegration and death of the tissues which thay affect. We 
do not intend to pursue this question further, or to speak of that form of 
death which results from the direct action of destructive agents ; but we 
purpose discussing very briefly the subject of necrosis, or mortification. 
This often arises in the course of inflammation, and often affects rapidly- 
developing morbid growths ; but whether occurring in these cases, or 
under other morbid conditions, it is always due immediately to obstruction 
of afferent vessels, or to weakness of the heart's action, and the conse- 
quent more or less complete arrest of the supply of nourishment to the 
affected parts. 

When the death of any part of the organism takes place, the conserva- 
tive influence of vitality ceases in it, its constituents fall under the unre- 
strained operation of chemical and other physical powers, and then undergo 
a series of destructive and often putrefactive changes, in virtue of which 
its complex organic constituents gradually get reduced to substances of 
much more simple elementary composition, and its various morphological 
elements lose in a greater or less degree their characteristic features. The 



102 



ATROPHY, DEGENERATION, AND NECROSIS. 



rapidity, however, with which these processes take place, necessarily de- 
pends upon the degree in which conditions which favor them happen to be 
present. These are chiefly heat, moisture, and exposure to oxygen or air, 
and to the various microscopic organisms which air and water contain. 
Hence, it follows that gangrene is especially rapid, and its products espe- 
cially fetid, when it occurs in superficial parts, or in the lungs, or in the 
course of the alimentary canal, where there is free exposure to oxygen in 
a more or less diluted form ; or when it occurs in parts which are juicy and 
loaded with blood, as they are if they have been the seat of inflammation, 
or if there has been previous obstruction of veins, or if the arteries have 
continued for a time to pump blood into them — when in fact the gangrene 
is what is usually called ' moist.' When there is little moisture of tissue 
and that moisture admits of ready removal by evaporation, or in other ways 
and especially if there be at the same time entire protection from the influ- 
ence of atmospheric air, the changes which ensue are very slow ; the parts 
get inspissated, dried up, mummified ; and even delicate structures retain 
for a great length of time their chemical and microscopical characters, in 
a very slightly modified condition. A good example is afforded by the 
changes which ensue in an extra-uterine foetus long retained. 

Bone, teeth, hair, horny matter, elastic fibres, and cartilage resist putre- 
factive processes in a remarkable degree. But all the softer albuminous 
or albuminoid tissues, and fat, rapidly change into a series of transitional 
compounds, the nature of which is very imperfectly known, some, how- 
ever — such as leucin, tyrosin, margarin, pigment, cholesterine and triple 
phosphate — are fixed ; some are soluble but not volatile ; and others again 
are volatile and offensive, and give to gangrenous parts their characteristic 
fetor. Amongst the last must be included sulphuretted hydrogen, sulphide 
of ammonium, and valerianic and butyric acids. Ultimately, most albu- 
minous and fatty matters are reduced in large proportion into carbonic 
acid, ammonia, and water. 

The visible changes which attend gangrene are not less remarkable 
than the chemical ; but they closely correspond with those which charac- 
terize ordinary degeneration. The blood stagnates; and soon the coloring 
matter escapes from the red corpuscles, permeates the vessels, and infil- 
trates and stains all the tissues around. Thus, the course of the superficial 
veins gets indicated by broad livid lines. Soon the diffused pigment is 
deposited in tjie form of brown and black grains and even of hsematoidin 
crystals, and its presence tends to give a characteristic hue to the parts. 
The red corpuscles themselves either melt away, or are converted into 
small angular pigmented bodies. The white corpuscles of the blood and 
other protoplasmic masses get opaque and granular, then the seat of depo- 
sition of molecules of proteinous matter and of oil, and finally after becom- 
ing caseous break up into fragments. The contents of fat-cells ooze through 
their membranous parietes, and diffuse themselves in globules of various 
sizes among all the tissues ; and after a while the solid fats crystallize out, 
and plates of cholesterine make their appearance. Muscular tissue, whether 
striped or unstriped, suffers much the same changes as protoplasm ; it first 
becomes opaque and granular, soon presents oil and pigment-granules in 
its substance, and presently breaks up (the striped fibres often splitting 
into transverse disks) and forms a viscid confused mass. Double-contoured 
nerves early present obvious changes :— the axis cylinder undergoes the 
same transformations as other forms of protoplasm ; but the medullary 
sheath breaks up into globular, oval, and irregularly rounded, refractive 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



103 



masses of an oily character, and presenting the peculiar features of what 
is termed by Virchow ' myeline.' Ordinary connective tissue swells up, 
becomes opaque and granular, and then melts away. And bone, although 
it retains its characteristic form and appearance, loses its animal matrix. 

Many lowly organisms make their appearance in putrefying tissue. But 
by far the most important of these are the minute omnipresent bodies 
which are known by the name of 1 bacteria.' Indeed the evidence now 
seems to be conclusive, that actual putrefaction is determined by the 
growth and multiplication of these bodies, and that the recognized effects 
of air and moisture in promoting the decomposition of dead and dying 
tissues are in reality due to the bacteria suspended in them. 

We have adverted to the fact that the appearances and progress of gan- 
grene vary according to the degree in which the dead parts are exposed 
to the conditions which promote putrefaction. But the nature of the organ 
involved also necessarily influences the nature of the result. Hence, we 
need not be surprised that gangrenous parts present great varieties of 
character. In internal organs, as the brain, the dead portion becomes soft 
and pulpy, and its color opaque and yellowish, with perhaps a faint green- 
ish tinge and a little red mottling, and the cellular constituents get granular 
and fatty, and presently reduced to a mere detritus ; but no putrefaction 
ensues, no offensive matters are developed, and the more soluble and dif- 
fusible products are at once removed from the part by absorption. When 
an inflamed or congested leg, or a strangulated bit of bowel, becomes 
gangrenous, the affected part contains an extraordinarily large quantity of 
blood which escapes into the tissues, and assuming there the characters of 
black pigment, blackens them ; putrefaction takes place rapidly ; a sanious 
fluid charged with decomposing elements, and containing numerous globules 
of oil and much pigment, pervades the tissues and perhaps forms blebs at 
the surface; and bubbles of offensive gas probably appear in similar situa- 
tions. When gangrene occurs in the lung, the tissue often looks anasmic 
(sometimes, however, it is black with congestion), and presents in the 
first instance a translucent greenish tinge, but soon breaks down into a 
turbid greenish pulp of horrible fetor. In other cases again, as for example 
in sloughing ulcers, or carcinomatous growths, the parts which are actually 
dead assume a dirty opaque white or grayish appearance, and are thrown 
off in masses. Lastly, when the affected parts have been supplied with 
little blood, or rapidly lose the fluid which is in them by evaporation, the 
condition termed 1 dry gangrene' results. They then shrivel up, and gradu- 
ally, by the retention of the blood-pigment within them, acquire a deep 
maroon or black color ; and, as was before pointed out, their decomposi- 
tion proceeds very slowly, and they become dry and mummified. 

C. Mechanical and Functional Derangments. 

The various morbid processes of proliferation and degeneration, which 
have been described, bring with them a host of mechanical and functional 
disturbances, which form essential elements of disease, and are often far 
more important, at all events far more striking, elements than are those 
other lesions which give rise to them. As regards functional disturbances, 
indeed, it is obvious .that their presence implies the coexistence of some 
nutritive or other material lesion of the part or organ whose functions are 
disturbed ; and that their gravity must depend, far less on the amount or 
quality of this material lesion, than on the importance of the affected organ 



\ 



104 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 

in relation to the well-being of our higher faculties, or to the maintenance 
of life. Thus, a fibroma, connected with superficial parts, may attain 
enormous dimensions without materially influencing the general health ; 
whereas a very small growth of the same kind, involving the urethra or 
intestine, would probably soon cause mechanical obstruction, and induce 
the usual symptoms of strictured urethra or bowel. And thus, again, a 
tubercular mass or an hydatid may exist for some time imbedded in the 
substance of the brain, and yet give very little sign of its presence there ; 
whereas those functional disturbances of the central nervous organ, which 
we know as acute mania and epilepsy, depend on such slight lesions that 
they even now, in great measure, elude detection. 

1. Mechanical Derangements. 

These consist mainly of (a) displacements of organs, (b) compression, 
contraction, and impaction, (c) dilatation, and (d) rupture and extrava- 
sation. 

a. Displacement of parts is exemplified in the altered position which 
the heart assumes when it is subjected to the pressure of unilateral em- 
pyema, or of a mediastinal tumor, and which this organ, together with 
the lungs, acquires when there is extreme angular or lateral curvature of 
the dorsal spine ; it is shown also in hernia, intussusception, and- pro- 
lapse of the rectum, and in the various flexions and other displacements of 
the uterus. 

b. Compression, contraction, and impaction These conditions scarcely 

need explanation ; . yet it may be well to illustrate them by their effects on 
tubular organs. Compression of a tube means that it is reduced in calibre 
and perhaps modified in shape, by forces acting upon it from without ; 
contraction signifies that its bore is diminished by the inherent action of 
its own walls, or by morbid changes taking place in them — that there is 
in fact a 4 stricture*; ' impaction implies that its channel is occupied by 
some concretion or other foreign body. It is obvious that any of these 
conditions may end in the complete obstruction, or closure, of the tube. 

The effects of compression are manifested, when a large quantity of 
blood or serum is effused upon the surface, or into the ventricles, of the 
brain ; when the lung shrinks under the pressure of accumulated pleural 
secretion ; when the heart gets flattened, and incapable of dilating, under 
the influence of blood which has escaped into the pericardium from a rup- 
tured aorta ; when the trachea is squeezed by a goitre or aneurism ; when 
the intestines are strangulated by bands, or the mouth of a hernial sac ; 
when the rectum is flattened by the pressure of a diseased uterus. They 
are shown also in many cases in which organs are the seats of interstitial 
growths ; — in cirrhosis of the liver, the newly-formed fibrous tissue con- 
tracts upon the essential elements of the organ amongst which it is dis- 
tributed, and leads to their more or less complete destruction; and the 
same thing happens, as regards the nervous centres, in the morbid condition 
now commonly termed ' sclerosis.' 

Contraction may be due, either to spasmodic action of the part affected, 
or to some growth (inflammatory or other) involvingjt. As examples of 
the first condition we have temporary contractions — of the cerebral vessels, 
inciting epileptiform convulsions ; of the muscular walls of the bronchial 
tubes, causing asthma : and of the sphincter ani and compressor urethrae, 
producing spasmodic stricture respectively of the bowel and of the urethra. 



CYSTS. 



105 



As examples of contraction due to inflammatory or other such changes we 
may enumerate, obstructive disease affecting the several cardiac orifices ; 
laryngeal oedema ; malignant or other organic strictures of the oesophagus, 
the pyloric or cardiac orifice of the stomach, the ileo-coecal opening, or the 
anus ; and similar affections of any part of the genito-urinary apparatus. 
It need scarcely be added that smaller and even microscopic tubes and 
ducts, such as those of the breast, kidney, and sebaceous glands, may get 
simi]arly obstructed. 

Impaction There are few tubular organs in which impediment from 

this cause does not occasionally take place. In the vascular system, es- 
pecially in the systemic veins, thrombi or clots not unfrequently form, and 
cause obstruction. And in the same system, portions of such clots, or of 
inflammatory vegetations developed upon the cardiac valves, often get de- 
tached, and then carried onwards by the circulating fluid, until they reach 
some vessel too small to admit of their further progress, where consequently 
they get fixed, or impacted, and block it up. In the alimentary canal, and 
ducts which open upon its surface, concretions frequently form, and, be- 
coming lodged, cause more or less serious consequences : — thus, the ducts 
of the salivary glands may be obstructed by salivary calculi, the common 
hepatic duct by gall-stones, and the intestine also by gall stones of large size, 
or even by indurated faeces. In the intestinal canal, moreover, indigestible 
substances, purposely or accidentally introduced, such as masses of hair, or 
of vegetable fibres, and the like, ocpasionally form concretions. Calculi 
again are of extremely common occurrence in the urinary cavities and pas- 
sages. In considering this subject we must not forget to advert to the 
impaction, or (what is equivalent to impaction) the accumulation, of abun- 
dant or tenacious secretions in cavities of canals, by which they are apt to 
become choked; as occurs in cases of severe bronchitis, when the bronchial 
tubes are overloaded with muco-purulent secretion, and in inflammation of 
the kidneys, or Bright's disease, when the renal tubules get blocked up by 
epithelial masses, or by blood or fibrinous casts. 

c. Dilatation of cavities depends, for the most part, on some dispropor- 
tion between the pressure which their contents exercise upon their parietes, 
and the force which these parietes are capable of exerting in opposition to 
that pressure; and hence may be caused, either by unwonted accumulation 
of contents, or by undue weakness of parietes, or by the concurrence of 
these two conditions. It should be added that even when dilatation does 
not originate in morbid weakness (however produced) of the walls of a 
cavity, it very soon causes it. But dilatation may occur in cavities of new 
formation, as well as in such as are of normal presence, and hence its dis- 
cussion involves that of the growth, if not that of the origin, of cysts. 

Cysts are very commonly classified as a subdivision of tumors. A little 
consideration, however, will suffice to show that they differ essentially from 
true tumors (that is to say, from neoplastic or proliferating growths), in 
the facts, that they are not themselves neoplasms; and that when they 
occur, as they often do, in association with such growths, that association 
is a mere accident, depending either upon some structural peculiarity or 
upon some special tendency, of the part affected, or of the neoplasm itself. 
Cysts may be divided generally, in accordance with their mode of develop- 
ment, into at least four different groups, namely : (i.) those formed by dila- 
tation of natural cavities; (ii.) those resulting from distension of ducts; 
(iii.) those caused by extravasation of blood; and (iv.) those originating 



106 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



in the softening and destruction of tissue, or in the dilatation of natural 
alveolar spaces. 

i. Cysts by dilatation of natural cavities — Among these must be in- 
cluded the pleurae, pericardium, peritoneum, tunica vaginalis, and synovial 
cavities, distended with dropsical or inflammatory exudation.- They are 
exemplified also in the dilatations of the ventricles of the brain and cord, 
which constitute respectively the morbid conditions known as ' hydro- 
cephalus' and i hydrorrhachis,' and in the malformations of the same organs, 
termed ' encephalocele' and ' spina bifida.' Dilatations of the cavities of 
the heart, aneurismal tumors of arteries, varicose conditions of veins, ova- 
rian cysts, and cysts of the broad ligament, thyroid body, and many other 
organs, fall more or less obviously into this group. 

ii. Cysts by distension of ducts, or '■by retention,'' are even more common 
and more important than the last. We meet with them in the lungs, when 
the bronchial tubes are dilated, or when emphysema is present. They 
occur in all parts of the alimentary canal : in the oesophagus, when its 
walls are paralyzed, or there is obstruction at the cardiac orifice ; in the 
stomach itself, under analogous conditions; and in any part of the large or 
small intestines above the seat of an impediment, or when the parietes are 
weakened by inflammatory changes. When the hepatic, pancreatic, or 
salivary ducts are obstructed by concretions, the tubes behind get greatly 
dilated. Cysts from this cause are exceedingly common throughout the 
whole of the genito-urinary apparatus: as, for example, when the bladder 
is distended, secondarily to the presence of a urethral stricture; when, 
under similar circumstances, the ureters and cavities of the kidneys dilate; 
and when, owing to their obstruction, the tubules of the kidneys expand 
into renal cysts. They occur also in the uterus and Fallopian tubes, and 
in the tubules of the testes, in consequence of stricture or other impediment 
to the escape of their contents; and so again in the breast, and in the 
sebaceous, and almost all other, glands. 

A variety of this mode of formation of cysts has been observed, by Dr. 
Wilson Fox and others, in certain cases of multilocular cystic tumors of 
the ovary. They state, that papillary growths take place from the inner 
surface of a comparatively large cyst; that these, as they increase in length 
and bulk, get closely wedged together; and that they at length coalesce 
in numerous points, leaving irregular chinks between them — which chinks 
then, by the retention of the secretions of their parietes, gradually dilate, 
and ultimately form distinct cavities. 

iii. Cysts by extravasation. — Blood effused either into cavities, or into 
the substance of organs, undergoes a series of degenerative changes. In 
some instances these result in the softening and breaking down of the 
central portion of the clot, and in the consequent formation of a cyst. The 
best examples of such cysts are furnished by the brain and the cavities of 
the heart — in the former case, as a result of the changes which take place 
in apoplectic effusions; in the latter, as a consequence of the softening of 
coagula which have formed some time anterior to death. Clots imbedded 
in the substance of the brain almost always undergo absorption, and leave 
behind them cysts filled with clear fluid, traversed by delicate filamentous 
bands, and bounded by tissue still colored with blood-pigment; those oc- 
cupying the cavities of the heart break down into an opaque milky fluid, 
charged with degenerate blood-elements. It not unfrequently happens that 
cysts are formed in the interior of sarcomatous and other soft and highly 
vascular tumors, by exactly the same process as that which produces apo- 



FUNCTIONAL DERANGEMENTS. 



10T 



plectic cysts. It may be added that extravasated blood, especially if it be 
extravasated in successive strata, in many cases forms solid masses, which 
may then become organized, and constitute, according to their position, 
the various forms of ' blood-tumor' or hcematoma. 

iv. Cysts by softening of tissues These are generally due to the occur- 
rence of one or other of the degenerative processes, which have been de- 
scribed. We meet with them in abscesses, and in cases where tissues have 
undergone mucous, colloid, or fatty softening. Hence, putting abscesses 
on one side, they occur most frequently in proliferating growths ; and in- 
deed, in some cases of disseminated malignant tumors the tendency to 
become thus hollowed into cavities is general. Bursas in unwonted situa- 
tions must be included in this group. 

It may be worth while to point out, that, as cysts dilate under the influ- 
ence of their accumulating contents, their parietes, which often increase 
at the same time in thickness, tend to tear or yield at points in their outer 
surface; that thus, pits which gradually increase in area and in depth are 
formed; and that these not unfrequently end in perforation or rupture, and, 
in the case of cysts separated by a party-wall, in the establishment of com- 
munication between them. We should also mention that the inner sur ace 
of cysts, contained within the substance of proliferating growths, may, 
however the cysts have been produced, get lined with epithelium, and the 
seat of new outgrowths; and that hence we not unfrequently see fungous, 
papular, villous, or cystic formations, springing from the inner surface of 
such cysts, just as Lhey may spring from the diseased mucous, serous, or 
cutaneous surface. 

d. Rupture and Extravasation The occurrence of rupture and extra- 
vasation, to which the distension of cavkies and canals ultimately tends, 
is an event of great pathological importance, and often of the gravest 
danger. Such accidents are common, sometimes the heart is torn, and 
the pericardium consequently gets distended with extravasated blood. 
The rupture of aneurisms and of varicose veins is, we need scarcely say, of 
extreme frequency. In the lungs, the progress of vesicular emphysema is 
largely dependent on rupture of air-cells ; and in interlobular emphysema, 
and pneumothorax, we have not only laceration of tissue but extravasation 
of air. Laceration of the stomach in ulcer of that organ, or of the intes- 
tine in the course of typhoid fever, is attended with the escape of its con- 
tents into the peritoneal cavity. Again, abscesses and hydatid cysts often 
rupture, and discharge their contents ; and, indeed (as we have already 
pointed out), cysts of all kinds are liable, in various degrees, and with 
various results, to similar accidents. 

2. Functional derangements. 

To discuss these thoroughly would involve an analysis of nearly all the 
symptoms of all diseases. Morbid processes, indeed, are mainly recog- 
nized during life by the functional disturbances to which they give rise ; 
and some diseases — so far, at least, as we know them — are nothing more 
than groups of such disturbances. Every organ of the body, every particle 
of the organism, has its proper duties to discharge ; and, under the influ- 
ence of morbid processes, these duties become increased or diminished, 
and in either case probably more or less profoundly modified. The func- 
tion of the eye is to see, that of muscle to contract, that of the kidney to 



108 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



excrete urine ; but the eye may be unduly sensitive to light, or its power 
of distinguishing objects may be impaired; or it may see things which 
have no real existence ; muscle may contract with spasmodic violence, or 
it may be thrown into convulsive movements, or it may lose its power of 
action altogether ; the kidney may cease to excrete urine, or it may sepa- 
rate from the blood a portion only of the usual urinary solids, or it may 
discharge matters which are altogether foreign to the normal constitution 
of that fluid. In these, and in many other ways, the organs which have 
been named may present signs of functional disturbance ; and it is clear 
that similar observations may be made in reference to every other organ. 
We do not purpose, however, to enter here upon the consideration of 
functional derangements generally, for the most of them will best be dis- 
cussed when we come to speak of local diseases. But some, which are 
connected more especially with the vascular and nervous systems, enters 
so largely into the complex phenomena of disease, and form such important 
elements in diseases which are fundamentally distinct from one another, 
that it will be convenient to discuss them separately, and at once. We 
refer mainly to congestion, dropsy, fever, the typhoid condition, collapse, 
and death. 

a Congestion. 

Accumulation of blood in the vessels of a part is necessarily associated 
with dilatation of these vessels ; but, as we have pointed out in speaking 
of inrlanunation, this dilatation may be active, and the accumulation of 
blood therefore secondary to it, or it may be passive, the vascular walls 
yielding under the pressure of the blood within them. 

i. Active congestion is due to active dilatation of vessels, or, at any rate, 
to that kind of dilatation which may be evoked by reflex irritation, and is 
effected under the influence of the nervous system. This dilatation com- 
mences for the most part in the small arteries, and presently involves the 
capillaries and small veins. Active congestion is constantly connected 
with inflammation, at least in its earlier stages, and generally with morbid 
proliferation. And, as in health we recognize its temporary presence in 
the cheek which blushes with shame, and in the general surface after 
violent exercise ; so, in disease, we recognize its temporary presence in 
the hectic flush of phthisis, and in the general redness which attends many 
forms of febrile disturbance. 

ii. Passive congestion has been divided, unnecessarily as it seems to us, 
into two varieties, namely : — first, that which is dependent solely on loss 
of power in the walls of the dilated vessels ; and, second, that in which 
the dilatation is traceable to some mechanical impediment to the passage 
of blood through the veins. There is doubtless a theoretical distinction 
between them ; yet it is obvious that in both cases the dilatation is really 
passive, and due to the fact that vessels yield under the internal pressure 
to which they are subjected. The first case is exemplified by that dilata- 
tion of vessels which attends the latter stages of inflammation, and by 
that permanent enlargement of them which is often seen in the vicinity of 
old ulcers, and of inflammatory and other formations, and is so common 
in the noses and cheeks of persons who are given to drink, or have been 
exposed to the influence of weather, or suffer from acne rosacea. The 
second variety is observed generally in obstructive heart disease, and under 
analogous circumstances in limited districts of the body. In diseases of 



DROPSY. 



109 



the mitral valve, in emphysema and some other affections of the lungs, and 
especially in diseases of the valves of the right side of the heart, the blood 
gets delayed in the systemic veins — the trunk-veins, their tributary branches, 
and the capillary veins successively undergoing dilatation. We often see 
in such cases, groups of minute subcutaneous veins forming varicose tufts, 
persistent livid congestion of the nose and cheeks, of the hands and fingers, 
and of the feet and toes, due to general over-distension of their capillary 
veins and capillaries, and, more important than all, congestions of internal 
organs — especially of the liver, which assumes the 'nutmeg' condition, 
and of the kidneys, which get indurated and secrete albuminous urine. 
Again, whenever a vein gets obstructed by a thrombus, or by external 
pressure, the tributary veins undergo precisely the same changes which 
the veins undergo generally in heart disease. Thus, if there be an aneu- 
rism, or other tumor, in the upper part of the chest, and the descending 
cava or one of its branches be compressed by it, the veins of the head 
and neck and upper extremities, or those of one side of this portion of the 
body, get distended ; if the femoral vein be blocked up by a clot, the veins 
of the foot and leg suffer similarly; if the lateral sinus be obstructed, 
enlargement and congestion of the retinal veins, and of those of the conjunc- 
tivae and eyelids, not unfrequently occur. So also when, owing to cirrho- 
sis or other hepatic disease, the passage of blood through the portal vessels 
is impeded, the veins of the mucous membrane of the stomach and bowels 
become over-distended, and occasionally relieve themselves by actual 
hemorrhage. We may add that, the mere statical pressure of a column of 
blood, which is competent to produce a varicose condition of the veins of 
the lower extremities, is competent also to produce dilatation of the smaller 
veins and capillaries. Nor should we omit to point out, that mere feeble- 
ness of the heart's action, in other words, incompetence to propel the blood 
efficiently, as occurs in the later periods of heart-disease, leads to stagna- 
tion of blood in the capillary and other small vessels, and hence to passive 
congestion ; and that, on almost the same principle, obstruction of an 
artery, as we see in the lungs and kidneys, very often allows the territory 
to which it is distributed to become the seat of intense congestion and even 
of hemorrhage. 

b Dropsy. 

Dropsy is the accumulation of serous fluid within the cavities of the 
body, or in the areolar spaces of the connective tissue. It depends either, 
like passive congestion, upon mechanical obstruction to the flow of blood 
along the veins, or upon the presence of inflammatory or other analogous 
processes, or upon some morbid condition of the blood or bloodvessels, or, 
lastly, upon obstructive disease of the lymphatic tubes or glands. Further, 
dropsy may be local or general, and dependent therefore on local circum- 
stances or on causes which act universally. 

i. The causes of general dropsy, or anasarca, are for the most part 
obstructive diseases of the heart, morbid conditions of the lungs impeding 
the circulation through the pulmonary vessels, affections involving the 
secreting structure of the kidneys, and certain morbid states of the blood 
or tissues. The general dropsy which attends heart or lung disease is, 
like the congestion which also attends these affections, purely mechanical, 
and indeed may be regarded as the sequel of that congestion. In the 
healthy condition the thin walls of the capillary vessels and small veins 



110 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



allow a constant escape of the serum of the blood into the tissues which 
are external to them — the quantity, which thus escapes in a given time, 
being largely dependent on the varying degrees of pressure within the 
vessels, and on the more or less facility with which the lymphatic vessels 
perform their proper absorbent functions. Now when a mechanical obstacle 
exists to the transit of blood through the heart or lungs, the systemic veins 
and capillaries soon get overloaded, and the pressure upon their inner sur- 
face rapidly rises. And we can readily see that, while there arises, on 
the one hand, a greatly increased tendency for the serum of the blood to 
transude at the peripheral distribution of the venous system ; there is de- 
veloped, on the other hand, a tendency at the opposite end of that system 
to impede the entrance of the contents of the thoracic duct ; and that hence 
the fluid, which is effused into the tissues in abnormal quantity, is absorbed 
with difficulty, and dropsical accumulation necessarily ensues. It should 
be observed, that the effusion is not simply, although it is mainly, fluid, 
but that it always comprises a considerable proportion of leucocytes, and 
generally some red corpuscles. Cardiac and pulmonary dropsies, are, as 
their mechanism would indicate, always associated with more or less ob- 
vious congestion, and almost invariably first show themselves in the parts 
which are most dependent. The explanation of renal dropsy is not so clear. 
It obviously does not depend on any obstacle to the circulation existing in 
the heart or lungs, or on over-distension of the venous system with blood, 
or, we may add, on any similar distension of the capillary vessels ; for the 
patient usually presents an aniemic appearance, even when the blood itself 
is not abnormally pale. There is, however, in renal disease very unmis- 
takable obstruction throughout the whole capillary arterial system; for, as 
Dr. Geo. Johnson has well shown, the small arteries generally become 
extremely thickened and their canals proportionately contracted; and we 
know that the left ventricle of the heart hypertrophies to overcome some 
impediment — doubtless the mechanical impediment which Dr. Johnson 
has discovered existing at the periphery of the vascular system; and that, 
associated with these conditions, there is. as we should expect, greatly in- 
creased blood-pressure in the arteries. It seems hardly likely, therefore, 
that in this case the escape of fluid into the tissues should take place 
through the capillaries and capillary veins; but, on the other hand, it 
seems very probable indeed that it occurs through the thickened capillary 
arteries, in consequence of the extreme internal pressure of fluid to which 
they are subjected. It can scarcely be objected to this explanation, that 
the thickened walls of the small arteries would materially counteract the 
tendency for fluids to transude through them, in face of the fact that the 
hyaline thickening of the walls of the Malpighian vessels of the kidney, in 
lardaceous disease of that organ, is not incompatible with a profuse dis- 
charge of urine. In pure renal anasarca the skin is usually remarkably 
anaemic and waxy-looking, and the dropsy is often first detected, not in 
the lower extremities, but in the eyelids and the scrotum. General dropsy 
occasionally takes place, in persons who, from whatever cause, are in a 
state of anemia; it is especially common in chlorotic girls. We know 
that in these cases the blood is in a state of unnatural dilution ; that the 
muscular tissue generally, including that of the heart and probably that of 
the bloodvessels, is enfeebled ; and that the circulation, therefore, even 
though the heart acts quickly, is languid ; and we are hence justified in 
assuming that the anasarca is due either to the fluidity of the blood, or to 
the languor of the circulation, or to a combination of these conditions 



DROPSY. 



Ill 



It need scarcely be remarked that the supervention of anaemia, in the 
course of disease of the heart or kidneys, is very often the determining 
cause of an attack of anasarca which otherwise would have been escaped ; 
and that anaemia is, in many respects, a very serious complication of the 
diseases of these and other organs. 

ii. Local dropsy depends either on mechanical obstruction of the prin- 
cipal vein or veins, leading from the dropsical part, or on obstruction of 
the lymphatics, or on the presence of inflammatory or other like processes. 
When it depends on venous obstruction, we have, within a circumscribed 
space, very nearly the same conditions as those which, in cardiac disease, 
affect the whole body — a vein is impervious ; its tributary branches down 
to the capillaries get distended with blood ; the serum of which presently 
escapes into the tissues in larger quantities than the lymphatics are able 
readily to remove. The most important variety of local dropsy from venous 
impediment is that which takes place in the abdomen, when the passage of 
blood through the portal vein is impeded, as in cirrhosis, or by growths oc- 
cupying the transverse fissure of the liver. But any vein may be obstructed, 
either by pressure from without or by a coagulum within it. Thus, by ob- 
struction of the superior cava enormous anasarca, limited to the head and 
neck and arms, may be produced ; from obstruction of the inferior cava (even 
from so slight an amount of it as results from the pressure of ascitic fluid) 
dropsy limited to the lower extremities may arise ; and, in consequence of 
obliteration of the brachial or femoral vein anasarca of the corresponding 
arm or leg may ensue. It lias already been pointed out that, whenever in- 
flammation is in progress, a considerable excess of the serum of the blood is 
poured out into the tissues ; and that, especially when the parts involved 
are lax or present some suitable structural peculiarity, the effused serum 
accumulates in them, producing a more or less obvious dropsical condition. 
We see this in the oedema of the eyelids, which attends the formation of a 
common stye; in the dropsical condition of the tissues around the joints, 
in rheumatism and gout ; in the cedematous state of the leg, when ery- 
thema nodosum or slight periosteal inflammation is present ; but we see it 
especially in inflammation of the serous and synovial membranes — thus in- 
flammation of the pleura constantly causes hydrothorax, inflammation of 
the pericardium hydropericardium, inflammation of the peritoneum inflam- 
matory ascites, and inflammation of the synovial membrane hydrops articuli. 
The effusion of serum in excess also attends the development of tubercle, and 
of carcinoma and other forms of malignant growths ; and consequently 
we often find the serous cavities full of dropsical fluid, in connection with the 
growth of such tumors from their parietes. It may, perhaps, be a ques- 
tion in some of these cases, as to how far the dropsy is due to the mere ex- 
cessive effusion naturally attending morbid proliferation, how far it may be 
attributed to obliteration of some of the veins leading from the great omentum 
and other parts. The remaining form of dropsy to which we have adverted 
is that which is due to lymphatic obstruction. We have already briefly con- 
sidered this subject in connection with both fibroma and lymphoma ; and 
need say no more about it now, than that the lymphatics of a limb or organ 
occasionally get obstructed, and that then (to take the case of the limb) the 
whole member becomes tense, elastic, pale, and infiltrated with fluid, having 
the chemical and microscopical characters of lymph ; that the tissues thus 
soaked in nutrient fluid tend to become hypertrophied ; and that here and 
there subcutaneous vesicles, which may be regarded as simply dilated lym- 



112 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



phatic passages, make their appearance, and from time to time rupture, and 
discbarge large quantities of lymph. 

In cases of general dropsy, whether of cardiac or of renal origin, both 
the general connective tissue and the various serous cavities, as a rule get 
involved in pretty nearly equal proportion ; but now and then, in association 
with slight anasarca, there may be extreme ascites, or extreme effusion into 
one of the pleuras. In such cases the local excess is necessarily due to the 
co-operation of some local cause — the ascites, for example, to a nutmeg con- 
dition of the liver, or to some slight peritoneal inflammation ; the pleuritic 
accumulation either to slight general pleuritis, or to the circumscribed in- 
flammation of the pleura which is usually excited in the neighborhood of 
pulmonary apoplectic clots. 

c — Fever. 

By the term 'fever' is meant that abstract condition which is common 
to all so-called ' febrile disorders,' and the presence of which gives them 
their claim to that designation. Essentially it means, undue elevation of 
temperature; the immediate or proximate causes of that elevation; and the 
consequences which these conditions entail. 

i. The normal temperature of the body has been variously estimated ; 
but, on the average, seems, in the adult, to range between 98-4° and 99-5°, 
in the infant, to stand at a somewhat higher figure. It presents however, 
within narrow limits, numerous variations. First. The most constant and 
important of these is the diurnal variation, which rarely exceeds 1-5°, but 
occasionally amounts to as much as 3-5°. The minimum temperature, 
according to Dr. Jiirgensen, occurs from 1.30 a.m. to 7.30 a.m. ; the max- 
imum from -1 p.m. to 9 p.m the temperature between 7.30 a.m. and 

4 p.m. rising with some fluctuation; that between 9 p.m. and 1.30 a.m. 
gradually falling. This daily variation corresponds pretty accurately to 
similar variations in the activity of respiration and circulation. Second. 
A slight but decided elevation of temperature usually follows the inges- 
tion of food. Third. Muscular exercise has a similar influence; although, 
as Dr. Davy has shown, this elevation manifests itself, less by actual in- 
crease of the temperature of the internal organs, than by the general 
diffusion of temperature throughout the organism. Fourth. The external 
temperature, again, influences that of the body in a greater or less degree. 
But, under ordinary circumstances, its influence is much less than might 
be supposed ; for variations of season in our own climate have a scarcely 
perceptible effect, and even tropical heat and arctic cold rarely disturb the 
temperature of the internal organs beyond a degree or two. The influence 
of external temperature depends, however, upon the conditions under which 
it is exerted ; for, if these be favorable, the general heat of the body may 
be very largely and rapidly augmented or lowered, and even to a degree 
which is incompatible with the maintenance of life. Thus, whenever the 
medium (air or water), in which the body is immersed, is in rapid move- 
ment, it will, if of a higher or lower temperature than the body, elevate or 
depress its temperature in a much greater degree than if it were at rest; 
and again, whenever perspiration is impeded, as it necessarily is in a 
moist atmosphere, or in water, the effects of heat are exerted with special 
efficacy.. 

The conditions which determine the heat of the body, and which regu- 
late it, have been investigated with considerable success. It is certain, in 



FEVER. 113 

accordance with the laws of force, that no heat can be developed in the 
body save such as may be traced, directly or indirectly, to the latent heat 
of the substances which are ingested as food ; that the total amount of heat, 
which the body is capable of evolving, is simply that which would be 
emitted in the course of its entire destruction by burning; and that, neither 
in its parts nor as a whole, has it any more power of creating heat than of 
creating matter. It is obvious, therefore, that the development of heat in 
the body is due simply to the setting free of latent heat by the destructive 
oxidation which is constantly going on in it; and that the quantity of heat 
developed in any given time is an exact measure of the amount of oxida- 
tion which has taken place in that time. It is equally obvious, that the 
excreta furnished by the skin, lungs, kidneys, and alimentary canal (re- 
presenting as they do the lowest degree of degradation to which, after 
various changes, the alimentary matters have become reduced), must fur- 
nish the means of determining exactly both the amount of oxidation 
which has been effected, and the amount of heat which has been evolved. 
Eanke, by comparing the daily quantity and quality of the food with the 
daily quantity and quality of the excreta, has arrived at the conclusion,, 
that the healthy adult body evolves on the average enough heat in twenty- 
four hours to raise 44 lbs. of water from the freezing to the boiling point.; 
and it has been estimated further, that of this heat 2*6 per cent, goes to 
the elevation of the temperature of the food ingested; 5*2 per cent, to the 
warming of the air breathed; 14-7 to the vaporization of the water dis- 
charged by the lungs ; and 77*5 to the radiation and evaporation from the 
skin. 

The above statements, however, only represent the final result which is 
attained, after many transmutations within the body, during which heat 
becomes alternately latent and sensible. We know, for example, that heat 
is as essential for the maintenance of the corporeal functions, as it is for 
that of the functions of the steam-engine ; that every act of growth and 
development, every nervous operation, every muscular contraction, is de- 
pendent on the heat developed by oxidation, and is attended with the tem- 
porary disappearance or absorption of a certain quantity of heat ; while., 
on the other hand, everything which interferes with, or impedes, or arrests, 
the performance of these functions — the friction of the blood against the 
capillary and other vessels, and of the muscular fibres against one another, 
every opposed muscular effort, and possibly even the constant passage of 
nervous currents along the nerves — is attended with the reappearance of 
that heat in a sensible form. 

It remains to consider on what conditions the regulation of the amount 
of heat developed, and the regulation of the temperature of the body, 
depend. 

As regards the former question, there can be no doubt that that degra- 
dation of tissue and of material which results in the evolution of heat, 
although in itself a purely chemical process, is indirectly largely under the 
influence of the nervous system, and especially of its sympathetic portion ; 
for it is to this heat that the varying rapidity and force of the heart's contrac- 
tions, and the varying diameters of the vessels (which between them so 
powerfully affect the molecular changes which are going on in the body) 
are due ; and it is possibly by its direct operation on the essential elements 
of glandular organs that the secretions of these organs are to a large ex- 
tent regulated. 

The maintenance of the body at a uniform temperature is due to the 
8 



114 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



existence of a remarkable power of adjustment between the amount of heat 
developed in the interior of the body, on the one hand, and the amount of 
cooling, on the other, which takes place during respiration by the admission 
of cold air and the exhalation of water, and at the cutaneous surface by 
radiation and evaporation — processes, however, which again are under the 
control of the nervous system. It scarcely need be added, perhaps, that 
the equalization of the temperature of the body is dependent on the circu- 
lation of the blood : that the more active this is, the more does the tem- 
perature of the surface and extremities approximate to that of the internal 
organs, while at the same time the more rapidly is the general cooling of 
the body effected ; but that, on the other hand, the more feeble the circu- 
lation, the cooler do the surface and extremities become, the wider 
grows the difference between the temperature of these parts and that of the 
interior of the body, and the more slowly does the internal temperature 
undergo reduction. 

ii. 1 The presence of abnormal or febrile temperature is usually attended 
with various symptoms and phenomena more or less characteristic of the 
febrile state. The skin gets hot, the pulse and respirations accelerated, 
the gastro-intestinal functions impaired or modified, the urine and other 
secretions diminished ; and headache and muscular pains are complained 
of. There is generally also a tendency for the febrile phenomena to assume 
a remittent character, for paroxysms to recur perhaps once or twice in the 
twenty -four hours, and for each paroxysm to comprise three more or less 
distinctly marked stages — namely, a cold, a hot, and a sweating stage. In 
the first of these the patient feels chilly or cold, shivers or has rigors ; in 
the next his skin gets hot and dry ; and in the third more or less abundant 
perspiration breaks out. 

The increase of temperature may vary from the slightest rise above the 
normal up to 110° or 112.° If it do not exceed 101°, slight febrile action 
only is present ; if it lie between 101° and 103° the febrile condition may 
be regarded as 'moderate;' if between 103° and 105° the fever is con- 
siderable or 'high ;' if it exceed 105° the febrile disturbance is excessive 
and there is usually considerable danger; from 106° upwards the tempera- 
ture is frequently termed ' hyperpyretic^ and (with one or two notable ex- 
ceptions) if it surpass 107° or 108° death is almost certain to supervene. 
Febrile temperatures, like normal temperatures, undergo variations ; and 
on the whole (excepting when interfered with by the influence of specific 
diseases) these correspond to the normal variations, but are exaggerations 
of them ; thus, there is usually a matutinal fall, and an evening rise, and 
the difference between them generally amounts to 2 or 3 degrees ; but it 
may be much more considerable. 

The skin is usually dry and hot; but it is liable to considerable changes. 
Thus, not unfrequently, during the early period of a febrile attack, or of a 
febrile paroxysm, while the internal parts of the organism are preternatu- 
rally hot, the vessels connected with the surface of the body, especially of 
the limbs and head and face, are so contracted as to allow comparatively 
little blood to reach the surface. This then looks shrunken and dusky, 
and in certain parts, especially the hands, feet, nose, and ears, may even 
be much colder than natural. But more or less general heat of skin is 

1 Several corrections and additions to this article have been derived from Dr. 
Burdon Sanderson's papers on ' The Process of Fever' in the Practitioner for 
1876. 



FEVER. 



115 



present even when the surface displays this appearance of chilliness ; and 
before long the contracted vessels dilate, blood is admitted freely to the 
comparatively exsanguine parts, which then become phimp, congested, dry, 
and often to the touch pungently hot. This latter condition is usually suc- 
ceeded after a time by more or less copious perspiration. 

The frequency of the heart's beats is always increased ; and this increase 
has usually some relation to the temperature present. Thus, if the latter 
range from 100° to 101°, the pulse usually ranges from 80 to 90 ; if the 
temperature from 101° to 103°, the pulse from 90 to 110; if the tempera- 
ture from 103° to 105°, the pulse from 120 to 130. With still higher 
temperatures, the pulse may rise to 140, 160, 180, or even over 200 beats 
in the minute. The rule, however, which is here laid down, is liable to 
frequent exceptions — especially in the case of irritable or nervous persons, 
in whom the pulse, in relation to temperature, is usually disproportionately 
frequent. The character of the pulse varies. In its typical condition it is 
more or less large, hard, and bounding, and its trace displays a sudden 
rise with an almost equally sudden fall, but no indication of dicrotism. 
This is its state during the height of fever. But during the cold stage it 
is small and hard ; and in the sweating stage large and soft. 

Although increase in the frequency of the respirations is undoubtedly 
one of the normal phenomena of fever, and we often observe the respira- 
tory acts rising to 30 or 40, and in the case of children to 50 or 60, in the 
minute, the respiration-rate does not bear that close relation to the tem- 
perature which the pulse-rate does. It is not uncommon to find the respi- 
rations normal in frequency even when the temperature is considerably 
elevated; and, on the other hand, to find them greatly accelerated in febrile 
states of the mildest type. When the temperature is hyperpyretic, the 
respirations are usually very rapid and shallow, and the inspirations often 
attended with opening of the mouth and of the alas nasi, and with a snif- 
fing, sipping, or sucking sound. The amount of air respired in fever in a 
given time is always considerably greater than in health, and although the 
expired air contains a diminished percentage of carbonic acid, the total 
quantity of carbonic acid discharged appears to be largely increased. 

Thirst is usually present, and often extreme ; for the most part there is 
impairment or loss of appetite ; the mouth feels dry and clammy, and ac- 
quires a bitter taste ; and the tongue tends to be more or less thickly coated 
and dry. The bowels are generally constipated. 

The urine is almost invariably modified in character ; it is scanty, high- 
colored, of high specific gravity, and deposits on cooling a more or less 
abundant sediment of urates and perhaps uric acid. But although the 
bulk of urine passed daily is generally below the healthy average, the 
quantity of solid matter which is passed with it is usually above the ave- 
rage. The chief increase here is in the urea, of which more than twice 
as much may be secreted as in health. Dr. Parkes has discovered 885 
grains in the day's urine of a patient suffering from enteric fever, Alfred 
Vogel as much as 1235 grains in that of one suffering from pyaemia, and 
Dr. Anstie over 1600 in that from a case of pleuro-pneumonia. Uric 
acid also is increased, and may be increased twofold. Again the coloring 
matter may amount to three or four times the quantity discharged in 
health, and there is a more or less important rise in the quantities of hip- 
puric, sulphuric, and phosphoric acids and of the salts of potash. On the 
other hand, chloride of sodium and other salts of soda are diminished. 
Febrile urine is usually more acid than healthy urine. But although the 



116 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



general fact of the increase of the solid constituents of the urine in fever 
has been well ascertained, it has also been well ascertained that the dis- 
charge of solid matters occasionally falls, sometimes suddenly, sometimes 
gradually, far below the normal, the urine becoming pale, limpid, and of 
low specific gravity. Such occurrences, however, are only of temporary 
duration, and sooner or later are always followed by an abundant discharge 
of effete matters which had been accumulating in the system. 

Among the febrile phenomena referable to the nervous system may be 
enumerated headache, vertigo, delirium, a sense of weariness, soreness or 
aching in the loins and limbs, and alternations of subjective chilliness 
with flushes of heat. The sensation of chilliness is exceedingly common, 
and occurs most frequently at the beginning of a febrile paroxysm. It 
is often associated with rigors. These are violent tremulous move- 
ments of all parts of the body — legs, arms, trunk, head, and neck — 
attended with chattering of the teeth and that pallor or duskiness of 
surface which has already been adverted to. The patient feels intensely 
cold, although the interior temperature of his body is probably far above 
the normal. Rigors appear to be due to the fact that, owing to undue 
contraction of its arteries, the skin receives less than its due share of 
blood, and less than its due proportion of the heat which is generated 
within the body. It is, therefore, either generally, or in certain parts, 
relatively cold. The feet, hands, nose, and ears, indeed, are often livid, 
shrunken, and actually cold. Rigors may not unfrequently be reinduced 
by exposing portions of the surface to the influence of the air. In children, 
convulsions sometimes take their place. 

There are several points of interest in relation to fever which may be 
briefly referred to. First. It is a remarkable fact that, notwithstanding 
the extreme thirst of most fever patients, and the large quantities of fluid 
which they drink, but little water comparatively is discharged from the 
kidneys or bowels, and often little apparently from the skin. Dr. Parkes 
suggests that this may be due to the presence in the system of some inter- 
mediate waste-product which, like gelatine, is powerfully hygrometric. 
There is reason, however, to believe that the collective discharge of water 
is usually much greater than it seems to be, and than it is in health, and 
that in fact a considerable proportion of the loss of body-weight of fever 
patients is due to this cause. If, then, the discharge of fluid from the 
bowels and kidneys be diminished, it is obvious that there must be aug- 
mented discharge from the lungs and skin. And, as regards the skin, it 
may be observed, that it is only during the cold stage and during rigors, 
that exhalation is in abeyance, that in the sweating stage the discharge of 
fluid is obviously excessive, and that even during the hot stage the escape 
of watery vapor by insensible perspiration is abundant. Second. The 
condition of the blood is a matter of much interest, yet little of import- 
ance is known about it. It seems, however, that after a time the red cor- 
puscles, albumen, and alkaline salts diminish in quantity — the blood con- 
sequently becoming impoverished. Third. That excessive waste of tissue 
goes on during fever is plainly shown by the condition of the urine, and 
by the gradual and often rapid emaciation of the patient, which takes 
place even if he be taking considerable quantities of nutriment. The tis- 
sues which especially suffer are the fat, which may almost entirely dis- 
appear, and the muscles, which dwindle away in a remarkable degree. 
But the more permanent tissues, such as the bones, also undergo some 
diminution. Recent observations show that although the amount of uri- 



FEVER. 



11T 



nary solids discharged daily in fever is often not larger than that discharged 
in health, it is always much larger than that which would be discharged 
in health under fever diet. It has also been shown that the increase in 
the urea precedes the elevation of temperature, and that it is maintained 
even during effervescence. That this urea is due mainly to the disinte- 
gration of the tissues of the body and of the blood-cells, and not, as in 
health, mainly to the albuminous matters derived directly from the food, 
is proved by the fact that the salts of potash (which are normal constitu- 
ents of the living tissues) become excessive in febrile urine, whereas the 
salts of soda (which abound in the plasma of the blood, and in food, and 
which in healthy urine exceed those of potash) diminish, sometimes almost 
to zero, to reappear in excess during convalescence, when the potash salts 
decrease. The undue disintegration of the red blood-cells is further proved 
by the excessive presence of coloring matter in the urine. Fourth. The 
supervention of convalescence is described as taking place in two different 
ways — either gradually by lysis, or suddenly by crisis. In the former 
case, all the febrile phenomena gradually disappear, and the patient lapses 
gently into convalescence. In the latter case the progress of the attack 
is abruptly arrested with the appearance of a so-called 'critical' discharge 
— copious perspiration, profuse diarrhoea, or abundant secretion of urine 
loaded with effete matters — by means of which it is supposed that the 
morbid blood rapidly purifies itself. Fifth, But fever may also end in 
death. This event, however, can rarely be attributed to the influence of 
fever alone, inasmuch as fever is always secondary to some specific or 
other disease of which it is a mere epiphenomenon or symptom. Never- 
theless it is obvious, if we consider the physiological and other recognized 
consequences of fever, that fever itself tends to the induction of death in 
some two or three different ways. The chief of these appear to be as- 
thenia, blood-poisoning, and the direct influence of sustained high temper- 
ature. The continuous excessive waste of tissue, with the consequent 
emaciation, loss of strength, and impairment of the functions of various 
organs (which is an essential element of the febrile state), must clearly, if 
it be not arrested, involve sooner or later a fatal issue. The progress of 
the hectic fever of phthisis, and other chronic wasting disorders, furnishes 
a sufficiently apt illustration. This waste of tissue necessarily leads also 
to the passage through the blood of an excessive quantity of effete pro- 
ducts, such as urea and other matters related to urea in composition, some 
or all of which are poisonous to the system in a greater or less degree. 
So long as these are freely eliminated by the emunctories, the blood may 
remain fairly pure, and but little mischief may ensue. We have shown, 
however, that this elimination is sometimes arrested temporarily. There 
is no doubt that it is often insufficient to effect the purification of the 
blood. Under such circumstances urosmic poisoning and typhoid symp- 
toms are only too apt to usher in a fatal issue. Lastly, the persistence of 
a temperature above a certain elevation is incompatible with the main- 
tenance of life. It has been shown by the experiments of MM. Delaroche 
and Berger that animals placed in an atmosphere ranging from 122° to 
201° until the heat had killed them, were found at the time of death to 
have an internal temperature of only 11° to 13° above their natural 
standard ; whence it may be inferred that an elevation to this degree is 
necessarily fatal to them. AVe do not, of course, know with any degree 
of accuracy what is the upper limit of temperature which is compatible 
witli the maintenance of life in the human being. We may say, however, 



118 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



with some degree of assurance, that a persistent temperature above 110° 
will certainly cause death, and that there is good reason to believe that 
a temperature of even 107° cannot be supported for any length of time. 
Death from high temperature is attributed by M. Bernard to a condition 
of the heart analogous to rigor mortis — the auricles are found full of 
blood, the ventricles contracted and empty. But the injurious influence 
of excessive heat is not exerted on the heart alone, but equally on all 
living tissues, and especially probably upon simple protoplasm wherever it 
is distributed. In cases of hyperpyrexia, the symptoms referable to the 
nervous system are particularly striking. They usually commence with 
more or less restlessness and confusion, and tendency to mental disturb- 
ance, and lead, through maniacal excitement, muttering delirium or con- 
vulsions, to coma and death. Nevertheless, it is by no means clear to 
what extent these symptoms are referable to abnormal heat. It is a re- 
markable fact that frequently, when the advent of death is attended with 
rising temperature, the heat of the internal parts continues to increase for 
some hours after death. 

It will be readily gathered from the foregoing discussion that the imme- 
diate cause of febrile temperature lies in the excessive degradation of the 
tissues of the organism, and the consequent evolution of their latent heat. 
The abnormal activity of circulation and respiration, which accompanies 
fever, alone implies unwonted activity in some at least of the processes 
which these functions subserve ; and the progressive emaciation of the 
frame, and the continued over-discharge from the lungs of carbonic acid, 
and presence in the urine (notwithstanding, in many cases, almost total 
abstinence from food) of an excessively large quantity of those matters 
which are the result of the degradation of albuminous compounds, clearly 
demonstrate the character of these processes. This explanation obviously 
does not touch that further important question, ' What is the cause of the 
tendency, which is always present in fever, to that preternaturally rapid 
destruction and oxidation of tissue on which the febrile elevation of tem- 
perature depends?' This question, however, notwithstanding its import- 
ance, scarcely calls for discussion here. 

The thermometer of late years has become to the physician almost as 
important as the stethoscope. It is in general use, and is certainly of ex- 
treme value, not only in the diagnosis, but in the prognosis of disease. 
It is desirable, therefore, to make a few observations in reference to it. 
A clinical thermometer should be accurate and sensitive, should have its 
degrees divided into fifths, and be so marked as to be easy of perusal. It 
should be furnished with an index, consisting of a single fragment of mer- 
cury, between one-fourth and one-third of an inch long, detached from the 
upper part of the mercurial column. For ordinary purposes an instru- 
ment, which maybe carried in the waistcoat pocket in a case, and marked 
from 95° to 112°, is sufficient. It is well, however, to be provided, for 
special purposes, with a thermometer of greater range (say from about 
80° to 112°), and probably, therefore, of greater length and comparatively 
cumbersome. The index should never be allowed to descend into the 
reservoir and so to mingle with the rest of the mercury ; nor should sup- 
plementary indices be allowed to detach themselves from the mercurial 
column. The former accident may be prevented by never violently shak- 
ing the index into the reservoir, and to some extent by the presence of an 
annular constriction in the channel of the thermometer a little above the 



HECTIC FEVER. 



119 



reservoir; the second, by always carrying the thermometer horizontal or 
with the reservoir downwards, and by never permitting the mercury when 
it has risen into the tube to be too suddenly cooled. Prior to taking a 
temperature, the index should be brought into the lower part of the tube, 
at least below the mark indicating the lowest temperature we are likely 
to meet with. The bulb of the instrument should then be placed in the 
part selected — in the axilla, beneath the tongue, in the anus or vagina — 
and retained there sufficiently long to permit of the rise of the mercurial 
column, and the carriage of the index, to the position corresponding to 
the temperature of the part. It is important, especially as regards the 
axilla, that the bulb of the instrument should be tightly grasped, and en- 
tirely protected both from the influence of the air and from the contact of 
the clothes, and that it should be allowed to remain in situ from three to 
five minutes at least. A casual observation is of course often of consider- 
able value; in many cases, however, and especially in fevers and inflam- 
mations, periodical observations should be made. Sometimes morning 
and evening determinations of the temperature are sufficient for all prac- 
tical purposes. But not unfrequently, especially in very severe and acute 
diseases, in certain specific diseases, or when the effects of particular forms 
of treatment are under investigation, periodical observations of much 
greater frequency are called for. 

Hectic fever.— The term i hectic' is applied to those varieties of fever 
which attend various diseases of long duration, and more especially such 
affections as malignant disease, tuberculosis and chronic syphilis, which 
are characterized by the gradual development of proliferating growths in 
many organs, or such as caries of bones, disease of joints, and the like, in 
which purulent discharges are kept up for an indefinite period. 

The phenomena of hectic fever are essentially those which have been 
described in the preceding account of fever. They are chiefly peculiar in 
their comparative mildness and long duration. The symptoms of hectic 
come on insidiously, and the febrile condition may be already far advanced 
before its presence is fully recognized. The patient probably finds himself 
gradually losing flesh and strength, and becoming disinclined for exertion. 
He observes that he is disposed to be chilly in the morning ; that in the 
evening, and in a less degree after meals, his hands and feet are hot and dry 
and his face flushed ; and that he wakes towards the morning with a moist per- 
spiring skin. But his tongue is clean, his appetite good, and, although he 
may be thirsty and his pulse quickened, his functions generally are properly 
discharged. At this time a careful thermometrical examination will pro- 
bably show his temperature to be elevated by two or three degrees ; but 
also that, as in health, it is lowest in the morning and highest in the 
evening, and that his indistinctly developed cold, hot, and sweating stages 
correspond pretty accurately with the usual cycle of the healthy tempera- 
ture-variations. 

As the morbid condition on which the fever depends progresses, the 
symptoms (although of the same character as before) get more distinctly 
developed, the patient becomes pallid, his emaciation and debility more 
obvious, and the febrile character of his illness more striking. The tem- 
perature, even now, often does not exceed 103° ; but it is liable to occa- 
sional higher degrees of elevation, and in its matutinal remissions may sink 
below the normal. The patient is apt to be chilly in the morning, with 
cold and livid feet, hands, and nose. In the evening exacerbation the skin 



120 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



gets hot and dry, the palms and soles burning hot, the lips dry and red, 
and the cheeks flushed with a circumscribed red flush ; and towards the 
morning he wakes to find himself drenched in profuse (colliquative) per- 
spirations. The chief exacerbation occurs almost invariably in the evening, 
and it is often the only one ; but there is occasionally a second, earlier in 
the day ; and generally the ingestion of food, and especially of an ample 
meal, is followed by more or less marked febrile reaction. With the 
progress of the other symptoms, the pulse becomes accelerated ; and even 
if it feels sharp, as it may do during the febrile exacerbations, it is posi- 
tively enfeebled, and undergoing progressive enfeeblement. Even now 
probably the tongue is clean, perhaps morbidly clean, and the appetite good. 
There is, however, more or less thirst, the bowels are probably constipated, 
and the urine (especially in the febrile paroxysms) is more or less scanty, 
high-colored, and concentrated. 

At a later stage the symptoms are modified, and other phenomena (not 
wholly referable to the fever) superadded. The emaciation and debility 
get extreme, the pulse more and more feeble and rapid, the circulation im- 
perfect ; bed-sores form; the fingers grow livid and bulbous, and the skin 
harsh and scaly; diarrhoea not unfrequently supervenes ; the tongue gets 
dry and fissured or aphthous; the appetite fails; and death from exhaustion 
presently ensues. 

It is remarkable that the intellect is rarely affected, and that, in a large 
proportion of cases, the patient continues cheerful and hopeful even to the 
last. 

d. — The Typhoid Condition. 

The condition here referred to, like fever, is common to many different 
diseases. When erysipelas, carbuncle, pneumonia, or any otner severe 
inflammation, is tending to a fatal issue ; in the later stages of typhus, en- 
teric fever, scarlatina, smallpox, and other specific fevers ; towards the fatal 
close of acute atrophy of the liver, and of uraemia consequent on Bright's 
disease; and at the corresponding period of many other affections; typhoid 
symptoms, or symptoms resembling those of the later stages of typhus fever, 
are apt to supervene. 

The patient becomes excessively prostrate ; he lies on his back in bed, 
with eyes closed, features shrunken and ghastly, and a dull stupid aspect, 
unconscious or nearly unconscious of everything that is going on about 
him. His skin is dusky, moist, and sometimes bathed in sweat, which 
often yields a fetid odor, and is for the most part, especially in the ex- 
tremities or exposed situations, cold. His lips are dry, black, and probably 
fissured, his teeth loaded with sordes, his tongue dry, brown or black, and 
often contracted in all its dimensions. He has no inclination for food, and 
probably no material thirst, but he has a difficulty (partly due to the con- 
dition of his mouth) in swallowing and utterance. His bowels are some- 
times constipated, but often relaxed, and the evacuations are apt to be 
offensive. His respirations are shallow, but for the most part not much 
accelerated — ranging probably between twenty and thirty in the minute. 
They may, however, be much more frequent, and are liable to variation. 
The pulse is rapid and feeble, and tends to get more and more rapid and 
feeble, and, towards the end, imperceptible at the wrist, and irregular. 
It may vary at first from 100 to 120, but often attains a frequency of 140' 
or more, and at the same time assumes an undulating dicrotous character. 



THE TYPHOID CONDITION. 



121 



The first sound of the heart is liable to become inaudible. It may be 
added that, shortly before death, the superficial capiilaries often dilate, the 
blood accumulates and stagnates within them, the surface acquires a rosy 
aspect, and a profuse flow of perspiration takes place. Bed-sores are apt 
to form upon the sacrum and other parts exposed to pressure. The con- 
dition of the urine presents considerable variety : — sometimes it is scanty, 
high-colored, and loaded with urates ; sometimes, on the other hand, it is 
abundant, pale and limpid, and of low specific gravity. Muscular debility 
is shown in the tendency which the patient has to lie upon his back, and 
to sink towards the bottom of the bed. His senses are blunted ; often he 
is deaf; he takes little notice (even if his eyes be open) of surrounding ob- 
jects ; he rarely complains of pain or uneasiness, or acknowledges its 
presence, and is insensible to conditions which at other times would have 
caused much personal discomfort; his intelligence is impaired; especially 
his memory fails ; his mind is full of delusions ; and he is more or less 
constantly muttering — he is in a condition of ' low-muttering delirium' or 
' typhomania he can probably, however, be recalled to himself momen- 
tarily if addressed loudly, and will then half open his eyes, endeavor to 
do what he is told, and even give an intelligent response ; but he soon 
lapses into the state from Avhich he was aroused ; he picks at the bed-- 
clothes ; his limbs are tremulous when he endeavors to move them ; and 
his muscular fibres are in constant vibratile movement, giving rise to the 
condition known as ' subsultis tendinum ;' he passes his evacuations un- 
consciously, or allows the urine to accumulate in his bladder. With the 
advance of the typhoid symptoms, the mind becomes more and more obtuse, 
and the patient gradually passes into stupor, and thence into profound coma. 
The temperature presents great variety, dependent in a considerable degree 
on the nature of the disease upon which the typhoid symptoms super- 
vene : — sometimes, as in Bright's disease, it is a good deal below the 
normal standard ; sometimes, as in the hyperpyrexia of acute rheuma- 
tism, it attains an elevation of 110° or more. The typhoid condition is 
always one of great gravity, and in a large proportion of cases terminates 
in death. 

The collective phenomena of the typhoid state have generally been 
attributed to the presence of some poisonous matter in the blood. For- 
merly this was believed to be the specific virus of the disease in the course 
of which they were developed ; or, in the case of local inflammations, some 
morbific elements generated at the diseased spot and thence thrown into 
the circulation. It is difficult, however, to understand how it can happen 
that numerous poisons, distinct from one another, and having different 
actions in other respects, should yet have the common property of inducing 
the complex phenomena of the condition under consideration. Another 
view is now commonly entertained, and has far higher claims to acceptance. 
It is to the effect that the poisonous matters which circulate in the blood 
are not the specific elements of diseases, but those products of the disinte- 
gration of nitrogenous tissues — urea and the like — which are known, when 
accumulated in the blood, to have poisonous effects ; and which are apt to 
accumulate in the blood in all those diseases in the course of which typhoid 
symptoms supervene. The excessive production of these effete matters in 
various local inflammations, and in the infectious fevers, is an established 
fact ; and as regards some of the latter diseases it has been distinctly proved, 
not only that the kidneys (even when healthy) often fail to eliminate them 
in normal quantity, but that even when these organs excrete them pro- 



122 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



fusely, the blood still remains overloaded with them ; and further that, in 
snch patients, when they have died with typhoid symptoms, urea in excess 
has been discovered in the blood. In chronic Bright's disease there is the 
same accumulation of urea and such like matters in the system ; and the 
typhoid symptoms which come on in its course have long been regarded 
as of ursemic origin. Indeed in this case it is impossible to suggest any 
other. The facts, of the presence of uraemia in all cases in which ty- 
phoid symptoms are present, and of the dependence of the typhoid symp- 
toms in Bright's disease upon the condition of the blood, are almost con- 
clusive in favor of the dependence of the typhoid condition generally upon 
ursemic poisoning. The circumstance that, in some cases the accumulation 
of effete matters is due to their over-production, in others to their retention, 
does not tend in any degree to invalidate this conclusion. 

e — Collapse. Syncope. 

The states of collapse and syncope are in many respects the opposite of 
that of fever, and are attended with either general or partial loss of tem- 
perature. It is important, however, to observe, that a general depression 
of the temperature of the body may take place, without any of the other 
symptoms of collapse being present, especially during the remissions of 
various febrile disorders, or the periods of convalescence from them;, and 
that, on the other hand, profound collapse may occur while the tempera- 
ture of the internal organs is still many degrees above the normal. 

The conditions under which collapse or syncope may supervene are very 
various. It may occur in the cases above mentioned — namely in the 
periods of remission of fevers, or during convalescence from them ; it may 
come on in rigors, or when (as in cholera) a high internal temperature 
prevails ; it may be consequent upon the presence of urea, or of extrane- 
ous poisons, in the blood. Other causes are mental emotions, more espe- 
cially such as are of a depressing character ; sudden and excessive pain ; 
unwonted distension of tubes (to wit, the urethra, the ureters, and the bile- 
passages) by foreign bodies ; rupture or perforation of internal organs ; 
hemorrhage, and profuse discharges, especially from the bowels ; vomit- 
ing ; severe injuries of all kinds, including those due to the operation of 
irritant substances or poisons upon the stomach ; mechanical obstacles to 
the cardiac circulation; and many others. 

The symptoms of collapse are mainly the following: coldness and pallor 
of surface, more especially of the extremities and face, which appear 
shrunken, pinched, and occasionally livid; perspiration, more or less pro- 
fuse, sometimes limited to the extremities and face, and generally forming 
large drops in the latter situation ; infrequency of the respiratory acts, 
which are shallow, sometimes scarcely perceptible, often irregular, and 
now and then sighing or gasping; feebleness of heart's action, indicated 
sometimes by increased frequency, sometimes by slowness, of the pulse, 
which often becomes irregular and often scarcely perceptible, or impercep- 
tible, at the wrist ; occasionally, hiccough and nausea, or even vomiting ; 
extreme muscular debility ; noises in the ears, indistinctness of vision, 
general soreness or sense of compression, want of breath, giddiness, de- 
pression or anxiety, and confusion of thought. In some cases there is 
restlessness, transient delirium or maniacal excitement, sometimes convul- 
sions, sometimes complete insensibility; in some cases, on the other hand, 
the mental condition is wholly unimpaired from first to last. In severe 



COLLAPSE — SYNCOPE. 123 

cases the patient lies almost motionless, with eyelids half closed and per- 
haps slightly twitching — looking like a corpse. In true collapse there is 
probably always more or less marked fall of temperature ; and that is the 
case even when, as in the collapse of cholera and other febrile disorders, 
the internal temperature is still abnormally high. But in all cases the 
extremities and the head lose heat rapidly, and usually become positively 
cold. In cholera, the thermometer in the mouth or axilla may stand at 
90° or less, while that in the rectum marks 105°; and in collapse, the 
result of severe injury, the temperature even in the rectum may fall (as 
is shown by Mr. Wagstaffe) as low as 82-15°. Much more commonly, 
however, collapse-temperatures range between 92° and 97°. 

Syncope differs from collapse (of w T hich indeed it is a mere variety) 
mainly in the suddenness of its access, and the rapidity of its progress, 
but generally also in the fact that the symptoms of syncope, during their 
continuance, are more severe than those of collapse. This latter distinc- 
tion is, however, by no means essential ; for, as is well known, syncope 
may present all degrees of intensity, from a simple sense of faintness to a 
prostration so profound as to simulate death. The short duration of syn- 
cope necessarily precludes the occurrence of any marked depression of the 
general temperature. 

When recovery from collapse or syncope takes place there is always more 
or less reaction; the surface gets smooth, its color returns, and a general 
glow supervenes, the circulation revives, the temperature rises, and other 
febrile phenomena manifest themselves. And if the collapse have been 
profound and of long continuance, the consecutive fever may assume seri- 
ous proportions. 

In considering the pathology of collapse there are three factors of that 
condition the importance of which is especially obvious. These are — de- 
pression of temperature, feebleness of circulation, and the condition of 
the nervous functions. First. The depression of temperature, so far as 
regards the limbs, face, and other exposed parts, can no doubt be traced 
mainly to the comparative failure of the circulation in them. But that 
this is not the sole cause of that depression is obvious from the fact that 
the internal temperature, instead of rising, as under such circumstances it 
should normally do, itself tends to diminish, and sometimes diminishes 
rapidly. It is clear indeed that there is throughout the organism a more 
or less complete arrest of those disintegrating processes upon which the 
maintenance of the temperature of the body depends, and presumably also 
a more or less complete arrest of those vital processes with which these 
latter are intimately interwoven. Second. The feebleness of the circu- 
lation is shown by the obvious weakness, and frequent irregularity, of the 
heart's action, by the failure, more or less complete, of the pulse at the 
wrist and in other peripheral situations, and by the concurrent disappear- 
ance of blood from the cutaneous surface and other textures. The details 
of the processes by which the failure of the circulation is induced doubt- 
less differ in different cases. It may, however, be assumed that there is 
always cardiac debility, and in a large proportion of cases diminished sup- 
ply of blood to the left side of the heart, and hence to the vessels which 
it supplies. In collapse from hemorrhage the latter condition is of extreme 
importance. And, indeed, it is found, in a large proportion of cases of 
death from syncope or collapse, that the cavities of the right side of the 
heart are distended, while those of the left side, and more especially the 
ventricle, are contracted and empty. In other cases, however (especially 



124 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



if death has been sudden), the left cavities may be found overloaded. 
Third, and most important, is the condition of the nervous functions. 
We have pointed out the not unfrequent dependence of collapse or syncope 
on affections of the mind, and on many other conditions which can be ope- 
rative only through the medium of the nervous system ; and we have enu- 
merated the various phenomena, referable to the nervous system, which 
attend and characterize a large proportion of cases. These facts are suffi- 
ciently suggestive. But when we look a little more closely into the matter, 
and consider how many different causes, of different operation, equally 
produce the same collective phenomena of collapse ; how rapidly these 
phenomena supervene, and how universally the organism is affected by 
them ; how impossible it seems that a smash of the leg, a perforation of 
the bowel, or an agony of terror, should directly arrest the chemical 
changes going on throughout the organism, and so reduce the temperature 
of the body, or should directly influence the action of the heart and arte- 
ries, it is impossible to doubt (what many other considerations tend to 
prove) that all the phenomena of collapse are directly traceable to the ope- 
ration of the nervous system — not however of the brain or cord, but of 
that department, namely, the sympathetic, whicli presides over circulation, 
nutrition, and the functions of the various organs, including those of the 
brain itself. 

f. — Death. 

Death is one of the natural terminations of disease ; and according to 
the nature of the disease, or the office, bulk, or position of the organ which 
may be its seat, the phenomena which usher in that event differ in a greater 
or less degree. Many of the specific fevers prove fatal with the superven- 
tion of typhoid symptoms ; many exhausting diseases cause death by 
simple debility or asthenia, and other affections by the allied conditions of 
syncope and collapse ; diseases of the air-passages or lungs prevent due 
aeration of the blood, and are fatal by asphyxia ; renal affections lead to 
the accumulation of urea in the blood, and death by uraemic poisoning ; 
and diseases of the brain induce coma, from which death presently results. 
In a large proportion of cases, no doubt, various morbid processes concur 
in the induction of the fatal issue. Nevertheless, a careful consideration 
of the phenomena of death enables us to bring the different modes of 
dying, numerous as at first sight they may appear to be, into a compara- 
tively small number of distinct groups. 

Bichat, in his ' Recherches sur la vie et la mort' speaks of ' death be- 
ginning at the head,' ' death beginning at the heart,' and ' death beginning 
at the lungs.' It is obvious, however, that these are not the only organs 
from which death commences ; and even those who follow Bichat most 
closely find it necessary to adopt his views with some modification or ad- 
dition. To us it appears that the principal sources of somatic death are 
to be found: first, in failure of nutrition; second, in failure of the circu- 
lation of the blood ; third, in failure of the emunctories to effect the elimi- 
nation of effete and poisonous matters ; and, fourth, in failure of the ner- 
vous system to perform its proper functions. 

i. Death from failure of nutrition This maybe due to many circum- 
stances, and may arise in the course of many diseases. It may depend 
on actual deprivation of food, as in simple starvation, or in obstructive 
disease of the oesophagus or cardiac orifice of the stomach ; or on persist- 



DEATH. 



125 



ent vomiting or diarrhoea, or any other affection (structural or functional) 
of the alimentary canal, which interferes with the due absorption of nutri- 
tious matters at the mucous surface ; or on the presence of diabetes, or of 
rapidly-growing malignant tumors, in which there is a misappropriation 
of the nutriment received into the blood ; or on the presence of inflamma- 
tory processes, or febrile disorders, in which excessive waste of tissue 
takes place without equivalent reconstruction ; or, lastly, it may be refer- 
able to the continuance of wasting discharges or losses of blood. The 
symptoms which precede death in these several cases depend largely upon 
the special conditions under which they arise, and are therefore liable to 
considerable variety. But such as are peculiarly referable to innutrition 
are, more or less rapidly increasing emaciation and debility, mental lan- 
guor, feebleness of circulation, and inability to resist the influence of ex- 
ternal cold. The general emaciation is not always proportionate to the 
muscular debility, which, after a while, becomes extreme. The patient 
probably lies upon his back, motionless or almost motionless, with hands, 
feet, nose, and ears more or less cold and dusky ; breathing feebly and at 
long intervals, with the pulse barely perceptible at the wrist ; sensible, but 
dull and languid, taking little notice, and not even caring to restrain the 
escape of his evacuations. With possibly no addition to the symptoms, 
the general feebleness passes almost insensibly into death — the last indica- 
tion of life being furnished by the barely perceptible movements of the 
heart. In simple starvation, there is a general lowering of temperature, 
which previous to death becomes considerable. Here life may sometimes 
be maintained for a while by the application of warmth. In disease, how- 
ever, although loss of temperature is not unfrequent, rise of temperature, 
under certain circumstances, is of common occurrence. 

ii. Death from failure of the circulation. — The failure may commence 
in various situations, may arise from many causes, and may come on with 
different degrees of rapidity. It most commonly takes place at the heart, 
which ceases to propel the blood : either from actual inability or failure to 
contract upon its contents ; or from spasmodic contraction which opposes 
the entrance of blood into it ; or from the compression exerted upon it by 
accumulation of serum or blood in the pericardial cavity ; or from the ob- 
struction of one of its orifices by clot, or some other equivalent cause. It may 
also depend upon obstruction of the pulmonary arteries by thrombosis or 
embolism ; or upon general contraction of their smaller branches, as occurs 
in asphyxia ; or upon similar contraction of the smaller systemic arteries, as 
probably happens in angina pectoris. Death from the causes here referred 
to may take place quite suddenly — the patient fainting and falling down 
insensible, and with a gasp or convulsive tremor yielding up his breath. 
It may take place less suddenly, yet still rapidly — the victim getting pale, 
cold, bedewed with sweat, insensible or nearly so, and possibly convulsed, 
with slow and shallow or gasping respiration, extreme feebleness of the 
heart's action, and imperceptible pulse. When the process of dying from 
failure of the circulation assumes a more chronic form, the phenomena of 
collapse are doubtless always present in a greater or less degree, and there 
is a more or less obvious disposition to depression of temperature ; but, in 
addition, the blood tends to accumulate and to stagnate in the capillaries 
and veins ; dropsy and congestion, with extravasation of blood, are apt to 
take place ; and not unfrequently the parts furthest removed from the in- 
fluence of the heart (nose, fingers, toes) become gangrenous. Certain 
differences in the details of dying depend, no doubt, on the situation in 



126 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



which obstruction occurs. It is stated that, if it take place suddenly on 
the right side of the heart or in the trunk of the pulmonary artery, ex- 
treme dyspnoea is one of the prominent symptoms. If, on the other hand, 
the sudden obstruction occur on the left side, insensibility and convulsions 
will probably be amongst the earliest of its consequences. Further, if gra- 
dual impediment arise on the right side of the heart or in the course of the 
pulmonary artery or its branches, more or less over-accumulation of blood 
will speedily ensue in the systemic veins and capillaries ; if such impedi- 
ment arise on the left side of the heart, the consequent congestion will first 
involve the pulmonary vessels. 

iii. Death from failure of the elimination of effete and poisonous mat- 
ters. — The poisonous matters, to which reference is here specially made, 
are those which accrue in the course of the disintegrating and secretory 
processes which are always going on, and are mainly, therefore — carbonic 
acid, which is evolved by the lungs; urea and other nitrogenous matters, 
which are discharged by the kidneys ; and some of the constituents of the 
bile, which are formed in the liver and under certain circumstances ab- 
sorbed into the circulation. 

The retention of carbonic acid in the blood produces the condition which 
is commonly known as ' asphyxia,' but might perhaps be better designated 
' anthracamiia.' It may arise in various ways : from obstruction of the 
larynx or trachea ; from bronchitis or other affections causing block of the 
bronchial tubes ; from disease of the lungs ; from mechanical impediment 
to respiration, due to accumulation of fluid in the pleural cavities; from 
paralysis or spasm of the respiratory muscles ; or from deficient supply of 
atmospheric air. The symptoms of sudden asphyxia are manifested in 
their typical completeness in cases of drowning, or of choking from the 
intrusion of a solid mass into the upper part of the larynx. The sense of 
dyspnoea is extreme, and violent but futile respiratory efforts take place. 
But soon vertigo comes on, the respiratory agony diminishes, and the 
efforts at inspiration get less violent. Gradually unconsciousness super- 
venes, convulsive movements may occur, and in the course of a few minutes 
all muscular action ceases. The heart continues to beat, perhaps for a 
minute or two, after respiration has come to a standstill. During the pro- 
gress of suffocation, the non-arterialized blood is impeded in its transit 
both through the small arteries and capillaries of the lungs, and through 
the corresponding systemic vessels, and the pressure of blood in the sys- 
temic vessels becomes augmented. But gradually, the obstruction getting 
more and more complete in the vessels of the lungs, less and less blood 
reaches the left cavities of the heart, and consequently less and less is 
propelled into the arteries; which also by gradually contracting on their 
contents drive them slowly onwards into the veins. Thus, while the pul- 
monary veins, left cavities of the heart, and systemic arteries, become 
comparatively empty, blood is gradually accumulating in the pulmonary 
arteries, right side of the heart and systemic veins and capillaries, and the 
general surface gets more and more livid and swollen,, and the superficial 
veins more and more obviously distended. But poisoning by carbonic 
acid takes place much more gradually, in the course of many diseases, and 
may extend over a period of many months. The general phenomena, in 
such cases, are essentially the same as those which have just been detailed, 
but they are, as it were, more diluted and of less intensity. The surface 
gets dusky or livid and cool, and the veins distended,, the right side of the 
heart dilated, the pulse quick, feeble,, intermittent; there is more or less 



DEATH. 



distressing dyspnoea and anxiety ; but gradually the struggle for breath 
grows less painful and violent, the patient gets drowsy, and rambles, and 
then, passing into a condition of coma and general debility, gradually 
sinks. 

The accumulation in the blood of urea and other matters, which should 
be eliminated by the kidneys, leads to many important consequences. By 
their slow action they induce more or less marked anaemia, contraction of 
the smaller systemic arteries, hypertrophy of the heart, and dropsy, with, 
sooner or later, impairment of the nervous functions, and especially de- 
lirium, eclampsia, and coma. It is to them also that are mainly due the 
collective phenomena to which the name ot 'typhoid condition' has been 
given, and which (as has already been pointed out) are apt to come on in 
the course of various febrile disorders and in structural diseases of the 
kidneys. 

iv. Death from failure of the nervous system to perform its proper 
functions. — Diseases of the nervous system are fruitful sources of death. 
Coma is not only a frequent precursor of death in cases in which the brain 
is not primarily involved, but it is a common symptom of grave cerebral 
lesions. In coma there is profound unconsciousness, the patient breathes 
slowly, irregularly, and stertorously, the saliva and other secretions from 
his mouth, throat, and air tubes accumulate in these several passages, and 
are not expelled ; and gradually, partly from this cause, partly from failure 
of the respiratory muscles, he dies of asphyxia. Again, spasm, or motor 
paralysis, may equally produce death by asphyxia : in epilepsy spasm of 
the glottis, in tetanus spasm of the muscles of respiration, may stop the 
breath and asphyxiate the patient ; and the like result may ensue from 
paralysis of the muscles of the throat and larynx, or of those that govern 
the movements of the chest. But in these cases it is obvious that, although 
death may be said to begin from the brain and cord, the patient dies in 
reality of carbonic acid poisoning. In truth, however, it is not the brain 
and cord, but the sympathetic system of nerves, which has the direct con- 
trol over the functions, the sum of which constitutes life. It is this which 
has within its grasp, so to speak, the whole of the circulatory system, the 
excretory, secretory, and nutritive processes, and even the functions of the 
brain itself : and it is to this system, therefore, that we should especially 
refer when we speak of death commencing from the nervous centres. It is 
to the influence of this system that both paralysis and spasmodic contrac- 
tion of the heart and bloodvessels are due; it is to the influence of this 
system alone that the phenomena of shock or collapse (which have been 
previously described) are directly referable. 

Now, although, in the foregoing paragraphs, we have distinguished 
several modes of dying, or groups of processes by which death is induced, 
it is obvious, if we come to compare them among themselves, that they 
have much in common, and tend to shade the one into the other. Thus, 
death from coma, or tetanic spasm, resolves itself eventually into death 
from asphyxia, and death from asphyxia into death from arrest of the 
circulation of the blood, and this arrest of the circulation of the blood into 
spasmodic and insuperable contraction of the pulmonary arterioles, which 
in its turn is referable to the influence of the vaso-motor nerves. And, 
indeed (excepting probably those cases in which death is induced by the 
sudden cessation of the heart's contractions under the influence of shock) 
the last obvious efforts of life are those of the heart ; the patient becomes 



128 



THE TREATMENT OF DISEASE. 



unconscious, the respiratoiy efforts cease ; yet still we listen for the sounds 
of the heart, and only when these finally disappear consider life extinct. 
But in neither shock nor asphyxia does the heart (at all events as a rule) 
cease to act because its muscular parietes have wholly lost their aptitude 
for contracting. In the former case the heart is, as it were, stunned, and 
may yet, under the influence of artificial respiration, have its movements 
re-established ; and in the latter case, where the heart seems to cease from 
sheer debility, this debility is rather in the ganglionic centres and nerves, 
which fail to supply the accustomed stimulus, than in the muscular tissue 
itself, which may still be made to contract under the influence of artificial 
stimulation. Hence it would seem that while, as a. rule, the cessation of 
the heart's beats may be regarded as the last observable phenomenon of 
life, this cessation, as well as that of many other phenomena of organic 
life, may in their turn be referred to the sympathetic system. 



V. THE TREATMENT OF DISEASE. 

Details of treatment are discussed, with more or less fulness, under 
the heads of the various maladies which are described later on in this vol- 
ume. There are, however, some general principles involved in the 
treatment of disease which it will be convenient to touch upon briefly here. 
They come mainly under the heads of ' Hygiene,' ' Prophylaxis,' and 
' Remedial Treatment.' 

A. — Hygienic Treatment. 

By the term t Hygiene'' is meant the science of health, or the study of 
those conditions on which the maintenance of health depends. Hygiene, 
therefore, takes cognizance — of the sanitary influences of the atmospheric 
and telluric circumstances among which we dwell ; of the conditions, in 
relation to density of population, ventilation, drainage, cleanliness and the 
like, in which we live ; of the quality of the water and food which we 
swallow ; and also of our dress and personal habits. The immense import- 
ance of attention to this department of medicine is beyond dispute ; yet 
the subject is so vast, and the details which it involves are so numerous, 
that it would be out of place to engage in their discussion in such a w ork 
as the present. 

But attention to the laws of hygiene is not less important for the wel- 
fare of the sick and convalescent, than it is for the welfare of those who 
are as yet in the enjoyment of good health ; and, indeed, it not unfre- 
quently happens that it is to hygienic measures rather than to drugs, that 
we must look for the cure of our patients. Even in this restricted sense, 
the subject of hygiene is too extensive to admit of satisfactory discussion 
within the limits of space at our disposal. It must be sufficient (by way 
of example) to refer — to the important beneficial influence which a mild 
balmy air exerts upon those who are suffering from inflammatory affections 
of the respiratory organs, or from pulmonary phthisis, and upon conva- 
lescents from many different diseases ; to the injury which cold winds or 
variable weather inflicts on rheumatic patients ; to the essential importance 
of treating the sick in airy, well-ventilated apartments, and of yet securing 



PROPHYLACTIC TREATMENT. 



129 



an equable genial temperature, of maintaining perfect cleanliness of the 
patient's person and of everything around him, of removing at once from his 
chamber all evacuations and other offensive matters, and of taking care that 
the water which he drinks is free from unwholesome impurity, and the food 
which he takes is of good quality ; and as regards those who are suffering 
from illnesses which do not necessitate confinement to the house, or those 
who are recovering, to the need for seeing that their dress is sufficiently 
protective against the weather, that they are not intemperate in meat or 
drink, and that they do not keep bad hours, or indulge in any other habits 
which are or may be hurtful. 

But different diseases are obnoxious to different injurious influences, and 
call for more or less important modifications in the employment of hygienic 
measures. But these are points which, so far as is necessary, will be dealt 
with subsequently. 

B. Prophylactic treatment. 

By 'Prophylaxis' is signified the preventive treatment of disease. In 
some respects this subject may be regarded as a part of hygiene, in some 
as a part of ordinary remedial treatment. We prefer, however (mainly for 
convenience of discussion), to look upon it as distinct from both. We 
understand by it the adoption of special measures to prevent the outbreak 
of special diseases which threaten, or the supervention of anticipated dangers 
in the course of diseases, and shall briefly consider it under the following 
heads : — 

1. Prophylaxis in relation to the tendency, inherited or acquired, to 
disease — We know that many persons derive from their parents proclivities 
towards certain diseases, such as phthisis, gout, epilepsy, and insanity. 
We know also that many of these affections may be induced, in those who 
are free from taint -of inheritance, by circumstances which tend to impair 
the general health. We«know, further, that exposure to similar conditions 
is peculiarly apt to act injuriously on those in whom such tendencies al- 
ready exist. And hence the importance, which is fully recognized, of 
adopting precautionary measures in reference to such persons : of sending 
the patient, in whom phthisis threatens, to an equable climate ; of restrict- 
ing the diet, and especially of curtailing the alcoholic drink, of him who 
has reason to anticipate gout ; and similarly with reference to many other 
affections. Again, there are many diseases of which one attack imparts a 
liability to subsequent attacks ; such are rheumatism, erysipelas and other 
inflammations, ague, and intermittent hematuria. It is obvious here, 
again, that it is of the utmost importance, for the welfare of the patient, 
that he should be protected from those injurious influences which he knows 
by experience to be the source of his malady. 

2. Prophylaxis in relation to parasitic, endemic, and infectious dis- 
eases — Many parasitic diseases are developed under circumstances which 
are well understood. Tape-worms are derived mainly from the use of 
the insufficiently cooked flesh of oxen and pigs ; and the trichina spiralis 
from the ingestion of that of the latter animal ; the Guinea-worm and the 
Bilharzia both prevail in certain regions. It is needless to dwell on the 
importance which the knowledge of such facts has in reference to the pre- 
vention of maladies of the kind. Endemic diseases are due to the opera- 
tion of local causes, a knowledge of the behavior of which, or of their 



130 



THE TREATMENT OF DISEASE. 



distribution, clearly furnishes an important clue to their prevention. Thus 
ague prevails in certain regions, goitre and cretinism in others ; and in 
both instances the occurrence of disease may be prevented by removal to 
some more salubrious district. In the former case, indeed, the malarious 
poison may be eliminated or destroyed by effectual drainage. Amongst 
endemic affections may be included ergotism from the use of spurred rye 
as food, and lead-poisoning from drinking lead-infected water, the suitable 
prophylactic measures against which are sufficiently obvious. Epidemic 
diseases are probably always directly or indirectly contagious ; but the 
several poisonous matters or contagia to which their spread is due, are 
thrown off from different parts of the organism, gain entrance into the 
system by different portals, and present in other respects essential differ- 
ences of habit. The knowledge that the contagium of typhus becomes 
especially virulent in the presence of over-crowding, and that that of re- 
lapsing fever has some peculiar relation with starvation, is of great import- 
ance in reference to the measures which should be adopted in order to 
prevent the development, or arrest the spread, of these diseases ; the knowl- 
edge also that measles is in the highest degree contagious previous to the 
occurrence of the rash, and that scarlet fever is comparatively little conta- 
gious during the corresponding period, or even for a few days subsequently 
to the appearance of the rash, is of importance also in reference to the man- 
agement of these affections ; again, the knowledge which we now possess 
that, while most of the exanthemata are propagated through the atmos- 
phere by the breath or cutaneous emanations, cholera and typhoid fever 
are only infectious through the intestinal excreta, and their poisons re- 
ceived into the system mainly by means of contaminated drinking-water, 
supplies us with practical data of the highest value, as to the methods by 
which their outbreaks should be dealt with. The fact that in most of the 
diseases coming within the epidemic class, one attack is protective in a 
greater or less degree against future attacks, is also of great importance in 
relation to prophylactic medicine. 

3. Prophylaxis in relation to the complications or sequelce of disease — 
ATost diseases bring in their train liabilities to specific incidents of more or 
less gravity — a fact, the appreciation of which enables us in many cases to 
take early measures for their prevention or alleviation. The knowledge, 
that rheumatism is apt to involve the pericardium or valves of the heart ; 
that, in scarlet fever, renal inflammation, albuminuria, and anasarca are 
liable to supervene ; that, in enteric fever, perforation of the bowel may 
take place at certain stages of the disease ; that, in gonorrhoea, the eyes 
may get infected and destroyed, enables us, in dealing with these affections, 
to take precautions which are often successful against the supervention of 
the mischances which have been enumerated. 

C. The remedied and therapeutical treatment of disease. 

The great aim of medical art is the cure of disease. Unfortunately, 
however, a direct cure — at all events a direct cure by means of drugs — in 
the great majority of cases is totally impossible. In some parasitic affec- 
tions, and more especially in such as involve the surface of the body, we 
may kill or expel the parasites, and so restore the patient to health ; by 
surgical operation or other mechanical measures, we may get rid of foreign 
bodies or concretions from internal cavities or canals, remove diseased 
parts, discharge the accumulated contents of normal or abnormal cavities, 



REMEDIAL TREATMENT. 



131 



reinstate displaced organs, dilate contracted channels, or, failing this, make 
new openings above the seat of obstruction, and so provide passages for 
the habitual escape of matters that need evacuation ; and we may, in a 
small number of cases, by the use of specific medicines or diet materially 
alleviate, and even cure absolutely, certain diseases : by arsenic or quinine 
ague, by mercury syphilis, by colchicum gout, by iron chlorosis, by fresh 
vegetables scurvy, and by suitable food, possibly rickets and some other 
affections. But neither by mechanical measures, nor by specific drugs, 
nor by the restoration to the dietary of matters in which it has been want- 
ing, can we cure the infectious fevers, internal inflammations, carcinoma, 
degenerative changes, or many of the functional and other disturbances to 
which the organism is liable. Most of these affections, indeed, take a 
course peculiar to themselves, tending in some cases to ultimate recovery, 
in some to chronic ill-health, in some to speedy death. We can do little, 
often nothing, to arrest them in their progress, or put limits to their dura- 
tion. And frequently all that remains to us is, by maintaining the patient's 
strength, by relieving symptoms, and by taking precautions against the 
supervention of complications or accidents, to enable him to pass with com- 
parative safety or comfort through his malady — hastening convalescence if 
the disease be one that does not necessarily end fatally, postponing the final 
issue if the disease be in the nature of things mortal. The chief general 
indications under such circumstances seem to be : 1st, to promote the 
patient's general comfort ; 2d, to support the patient's strength by appro- 
priate nourishment ; 3d, to maintain or to restore the healthy tone of his 
nutritive functions ; 4th, to promote the free action of his emunctories ; 
oth, to relieve the secondary phenomena or symptoms of his disease ; and 
6 th, to obviate the tendency to death. 

1. The rendering the patient's condition as comfortable as circumstances 
permit, involves of course careful and judicious nursing, and the closest 
attention to all hygienic and other details of management. The latter will 
necessarily differ in different cases ; but r in illustration of our meaning,, 
we may signalize the following points : keeping the room dark in eye-dis- 
eases, or where it is important to promote sleep ; maintaining quiet where- 
in brain diseases and other affections there is acoustic hyperesthesia ; sooth- 
ing the patient when he is irritable or excited ; raising his hopes and 
spirits when he is depressed or desponding ; and when he is in a condition 
to enjoy such pleasures, to gratify, without worrying, his mind with pleasant 
surroundings and diversions. It need scarcely be added that patients 
should always be kept as clean, dry, and free from undue pressure or fric- 
tion as possible, and should not be allowed to soak in their own discharges ; 
for in a large number of cases, and particularly in those of chronic wasting 
diseases, of inflammatory and febrile disorders in the typhoid stage, and of 
paralytic affections of the central nervous organs, there is a peculiar apti- 
tude, especially under such circumstances, for the speedy production of 
bed-sores. 

2. The maintenance of the patient's strength by the judicious adminis- 
tration of food is an essential element in the successful treatment of disease. 
In most diseases, the tissues of the body disintegrate with unwonted ra- 
pidity, and emaciation and debility tend to supervene in a proportionate 
degree ; and in most, this over-rapidity of disintegration is accompanied 
with loss of appetite, loathing of food, impairment of the nutritive func- 
tions, or some other condition, which renders it difficult to supply to the 
organism the alimentary matters necessary for its renovation and mainte- 



132 



THE TREATMENT OF DISEASE. 



nance. If the obstacle lie in the patient's determination not to take food, 
as is the case with some lunatics, food must be administered by means of 
the stomach-pump ; if it depend on some mechanical impediment in the 
oesophagus, stomach, or elsewhere, the food must be administered in such 
a form (for the most part fluid), and in such quantity, as will permit of its 
comparatively easy transmission through the constricted, compressed, or 
paralyzed part ; failing such measures, operative procedure of some kind or 
other may under certain circumstances become advisable. If the patient's 
inability to take food depend upon irritability of the stomach, this condi- 
tion must be remedied by suitable treatment, and all food administered 
meanwhile must be nutritious, unirritating, easy of digestion, and given 
in small quantities, and, if possible, frequently. Milk, barley-water, gruel, 
and the like, are generally best adapted for such cases. Occasionally, how- 
ever, small quantities of solid but well comminuted food are preferable. 
If the patient be suffering from inflammation or fever, or other constitu- 
tional conditions, in which utter abeyance of all desire for food exists (asso- 
ciated as such abeyance often is with irritability of the stomach, and even 
difficulty of swallowing), it is generally advisable, in order to insure the 
due administration of nutriment, to draw up some scheme for the guidance 
of the nurse or other attendants, — to determine how much food it is desir- 
able to administer in the twenty-four hours, the intervals at which it should 
be supplied, and the quantity which should be given on each occasion. A 
teacupful, a wineglassful, or a tablespoonful of fluid nourishment may, ac- 
cording to the nature of the case and the circumstances which arise, be 
directed to be administered every two hours, or hour, or half-hour. The 
quantity given at one time should never (if it can be avoided) be so large 
as to cause sickness ; and the frequency of administration must be regu- 
lated in some measure by the quantity which is given at each meal ; but 
we must not be disheartened if we find (as is too often the case) that the 
patient is unable to take the whole amount of nourishment which we have 
determined upon as his minimum allowance. In cases of this kind nothing, 
as a rule, can be better than milk ; and generally even those with whom 
it habitually disagrees can now take it with little difficulty; but it is often 
necessary to alternate its use with that of other nutritious fluids, such as 
gruel, barley-water, rice-water, arrowroot, corn-flour, or biscuit-powder 
properly prepared with water or milk, or beef-tea, mutton-broth, chicken- 
broth, or soups, or to replace it by them. Alcohol, in some form or other, 
is frequently necessary, and must then take its place in the rota. In all 
cases, whether of inflammation, fever, gastro-intestinal affection, or me- 
chanical obstacle to the entrance of food into the stomach, if the amount 
administrable by the stomach be insufficient to maintain life, nutritious 
enemata must be systematically used ; and, indeed, this mode of giving 
food may sometimes be employed temporarily with great benefit, to the 
total exclusion of that by the mouth, in cases of extreme irritability of the 
stomach. In many chronic diseases, such as pulmonary phthisis, the ap- 
petite often remains good, though perhaps variable and capricious, and 
hence it is a comparatively easy task to insure the due administration of 
nourishment. The appetite is generally good, also, during convalescence 
from wasting disorders, and for the most part may be taken as an indica- 
tion that the patient needs to be well fed. Although the rules above laid 
down are generally true, there are occasional exceptions to them ; and 
moreover special diseases in some cases need special modifications of diet. 
A day or two of abstinence or of starvation is often beneficial, sometimes 



REMEDIAL TREATMENT. 



133 



imperative ; and, again, the importance is obvious of the avoidance of 
amylaceous matters by diabetic patients, and of excess of nitrogenous food 
by those who are suffering from Bright's disease. It may be added that 
persons frequently come under our care who are suffering not only from 
disease, but from starvation, which may have commenced prior to the com- 
mencement of their disease or supervened upon it ; and that here especially 
the good effects of careful attention to the nutritive functions are often 
strikingly exemplified. 

3. It has already been hinted, in the foregoing paragraph, that in many 
cases it is essential for the successful exhibition of nourishment that the 
stomach and bowels should be first rendered capable of retaining and act- 
ing upon the alimentary matters which are introduced into them. It is, 
in fact, always important, in the presence of disease, to maintain, or as far 
as possible to improve, the general welfare of the nutritive functions. To 
some, and indeed to no inconsiderable, extent this end may be attained, 
as we have pointed out, by the judicious administration of food. But in a 
large proportion of cases tonic medicines of various kinds are of extreme 
efficacy in this respect. It is needless to indicate the numerous cases in 
which iron, cinchona, cod-liver oil, and the like, act almost as specifics in 
the cure of disease. We wish, however, particularly to insist on their 
value in the treatment of many morbid conditions, in reference to which 
they do not possess obviously specific powers. Among these we may name 
the various forms of dropsy, and many other consequences or secondary 
phenomena of organic lesions of the heart, lungs, liver, kidneys, and other 
organs. In such cases, it is generally necessary to adapt the form of tonic 
to the condition of the alimentary canal, or it may be to associate with it 
medicines which tend to soothe or stimulate the mucous membrane, or to 
act otherwise beneficially on it. 

4. The notion of getting rid of the poisonous elements of disease, by 
eliminating them by the various emunctories or other routes, is an old one. 
It happens unfortunately, however, that as a rule we have little or no 
power in thus discharging the proximate causes of disease. It is entirely 
beyond our competence to promote the separation from the system of the 
material factors of the various forms of inflammation, of the living elements 
of malignant growths, or of the contagia of the infectious fevers. Neither 
can we, by the use of drugs taken into the stomach, cause the elimination 
or death of parasites imbedded in the organism, or even of such as infest 
the surface of the body. It is very different, however, with regard to the 
effete matters which are so abundantly produced in many diseases, which 
so frequently tend in them to accumulate within the blood, and which so 
often by their presence therein cause toxaemic symptoms and thus add 
seriously to the clangers which the patient incurs. For this reason it is 
generally advisable to maintain, as far as possible, free action of the 
various secretory organs — the skin, kidneys, alimentary canal, and lungs. 
In febrile disorders not only is there usually a large over-production of urea 
and of matters related to urea, but the urine, by which alone they can be 
efficiently removed, is usually scanty. It is obviously desirable therefore, 
in these cases, to promote the flow of urine — a result which may generally 
be best attained by allowing the patient to drink freely. In gout, a some- 
what similar accumulation of effete matters, and especially of urate of soda, 
takes place in the blood, and consequently here again eliminative treatment 
is indicated. But it not unfrequently happens that poisonous matters accu- 



134 



THE TREATMENT OF DISEASE. 



mulate in the blood in consequence of structural disease of the organs by 
which they should be separated. In disease of the kidney, urea and other 
waste nitrogenous matters are retained in the blood, in disease of the liver 
the elements of bile, in disease of the lungs carbonic acid. Under these 
circumstances unconquerable obstacles frequently exist to the purification 
of the blood. Still, good may often be effected, if not by promoting the 
eliminative action of the implicated organ, at any rate by encouraging the 
vicarious action of other organs. In renal disease much benefit is generally 
obtained by the regulated use of drastic purgatives, and by promoting 
profuse perspiration ; and in liver disease with jaundice, by encouraging 
diuresis. Again many substances, poisonous and other, which occasionally 
gain entrance into the organism, tend, like urea, and other effete matters, 
to be thrown off — sometimes by the kidneys, sometimes by the lungs, 
sometimes into the parenchyma of certain organs. Their discharge may 
often be hastened by appropriate measures. It is an important statement 
that lead and mercury, which have an aptitude to be deposited in certain 
of the tissues, can be removed thence by means of iodide of potassium ; 
with which they are said to unite in the organism, and in company with 
which then to escape with the urine. But eliminative treatment is by no 
means called for in all diseases ; and, even where it is indicated, it must 
not be assumed that the emunctories must be powerfully stimulated into 
action, still less that we should act violently upon all at the same time. 
Here, as in other cases, we must be guided in our efforts by the nature of 
the case with which we have to deal, and by the phenomena which 
manifest themselves during its progress. 

5. No inconsiderable part of the duties which a medical practitioner is 
called upon to perform consists in the treatment of the secondary phe- 
nomena or symptoms of disease — in relieving pain or uneasiness, in giving 
sleep, in soothing irritability or anxiety of mind, in promoting or checking 
the action of certain organs, in removing or dissipating matters which, 
from their position or quantity, interfere with the due performance of 
functions that are important to life or health. And it is certain that, if 
we do not by such measures actually cure the primary disease, we often 
make life tolerable, we are often successful in prolonging life, and not un- 
frequently succeed in prolonging it until the disease, which would other- 
wise have carried the patient off, itself subsides, and by its subsidence 
leaves him convalescent. The importance of relieving pain in acute 
inflammation of the peritoneum or pleura, or in enteritis, and in various 
forms of neuralgia, is fully admitted by every one. The necessity of giving 
sleep in traumatic delirium, in the wakefulness which sometimes precedes 
the outbreak of acute mania, and in many febrile and organic diseases, is 
equally recognized. The relief of spasmodic action of the voluntary 
muscles in tetanus, or of the involuntary muscles in spasmodic stricture of 
the urethra and various other tubular organs, is often a matter of urgent 
need ; as also, on the other hand, is the stimulation of an inactive organ — 
of the heart under certain conditions, or of the flaccid uterus after partu- 
rition when profuse hemorrhage is taking place. The last examples which 
we shall adduce are supplied by the removal, whether by tapping or by 
medicinal means, of dropsical accumulations in serous cavities ; and the 
dissipation of effusions, tumors, or foreign bodies, which by their position 
compress or interfere with passages — such as the larynx, or bowel — the 
patency of which is necessary for the maintenance of life. 



REMEDIAL TREATMENT. 



135 



6. To obviate the tendency to death is to a great extent implied in the 
foregoing discussion. In a sense it is the principle aim of all medical treat- 
ment. The expression, however, is generally employed in reference to the 
duty which devolves upon us at the time when death appears to be immi- 
nent, and when the exact nature of the process by which death will be 
brought about becomes more or less clearly indicated. On a former page 
we have discussed the various modes of dying ; and we must refer to what 
was there said for the special indications for treatment furnished in the 
several cases there enumerated. 



PART II. 
SPECIAL PATHOLOGY. 



CHAPTEK I. 

SPECIFIC FEBRILE DISEASES. 

I. INTRODUCTORY REMARKS IN REFERENCE MAINLY 
TO THE INFECTIOUS FEVERS. 

A. Specific Origin and Spread of Epidemic and Endemic Diseases. 

The diseases, to«which the following remarks are intended to be intro- 
ductory, are for the most part linked together by the possession of certain 
striking characteristics. They originate severally in definite specific causes, 
they prevail endemically or epidemically, and are in large proportion in- 
fectious or contagious. 

1. They originate in specific causes To this subject we shall presently 

recur; meanwhile, the truth of the statement here made is proved by the 
fact, that the several diseases of this group never pass the one into the 
other, or (notwithstanding that, within certain limits, they may present 
variations of character) lose their specific identity — that while malarious 
poison never causes smallpox, typhus, or scarlet fever, so the specific poison 
of either of these latter affections never gives origin to ague, or to any 
other disease than that from which it was derived. Smallpox produces 
smallpox, typhus typhus, scarlatina scarlatina; and ague arises under spe- 
cial conditions which are productive of ague and of ague alone. 

2. They prevail endemic cdly or epidemically. — The term 'endemic,' as 
applied to disease, signifies the prevalence of disease among a people. For 
the most part, also, it implies its limitation within certain restricted arese, 
its dependence on local or localized causes, and a tendency to persist in 
the district which it affects. The term 'epidemic,' on the other hand, 
implies that the disease of which it is used falls as it were suddenly upon 
a people, and generally implies, further, that it spreads widely and rapidly, 
and that its prevalence is of limited duration. Goitre is the very type of 
an endemic disease, influenza perhaps the most characteristically epidemic 
of all epidemic diseases. It is important, however, to observe that epi- 
demic diseases comport themselves in many different ways, and that the 
epidemic and endemic conditions not unfrequently pass the one into the 
other. Influenza, and it may be added smallpox, scarlet fever, measles, 
and other like affections, when occurring for the first time in an unpro- 
tected community, diffuse themselves generally with marvellous rapidity. 



138 



SPECIFIC FEBRILE DISEASES. 



Typhus and relapsing fever, virulent though they be, limit their spread 
mainly to those who are under certain defective sanitary conditions. 
Cholera, though distinctly epidemic, diffuses itself mainly by irregularly 
scattered local outbreaks — a peculiarity still more markedly belonging to 
enteric fever and to diphtheria, which, moreover, are apt to persist in an 
endemic form, in the localities into which they have been introduced. 
Further, many affections, which are now more or less characteristically 
endemic, or epidemic within restricted area?, have been, or are liable to 
become, epidemic in the wider sense of the word, under certain ill-under- 
stood conditions ; among these may be enumerated leprosy, syphilis, plague, 
and yellow fever. 

3. They are in large proportion infectious or contagious It was for- 
merly largely believed, that epidemic disease was the result of the operation 
of some mysterious influence, diffusing itself like a vapor over the surface 
of infected regions, involving equally the whole population, modifying the 
general health, tincturing the already prevalent diseases, and causing among 
those who were predisposed to it the specific epidemic attack. This view 
was once held with regard to syphilis itself — a disease which is now known, 
like hydrophobia and glanders, to be imparted only by direct inoculation. 
It is even now held by many in respect of influenza — a malady which is 
one of the most eminently contagious of maladies, and in this respect allied 
with smallpox, scarlet fever, and measles. That the origins of cholera, and 
enteric fever were long enshrouded in mystery is not surprising; yet even 
in the case of these diseases there is now scarcely room to doubt their dif- 
fusion by means of specific contagia. And, indeed (though it has not yet 
been distinctly proved of every epidemic affection), the progress of patho- 
logical science leaves little room for doubt, that, all truly epidemic diseases 
are communicable directly or indirectly from the sick to the healthy, and 
that their spread is due solely to the operation of a specific virus which 
the former yield and the latter absorb. Endemic affections, on the other 
hand, are not necessarily infectious; and some — such as ague and goitre 
— seem clearly to originate in certain poisonous matters, developed, or 
existing, in the soil of the localities which they affect. 

4. Behavior of contagia within the organism. — The virus or contagium 
of an infectious fever, having gained entrance into a susceptible body, 
apparently remains dormant in it for a time, which varies according to the 
nature of the fever, and is termed the period of l latency' or ' incubation? 
To this succeeds the period of ' invasion,' during which the first symptoms 
of the disease manifest themselves. And on this soon supervenes, in its 
turn, the period during which the specific symptoms become declared. 
This, in the case of the exanthemata, is termed the '■eruptive' period. In 
other varieties of infectious fevers, the period of invasion, and that which 
corresponds to the eruptive period, are for the most part indistinctly 
divided. In most cases, after the symptoms have endured for some defi- 
nite time, they begin to abate — the period of decline, or defervescence comes 
on. On this convalescence ensues and the patient is presently restored to 
health. 

In order to impart disease, the contagium must enter into the system. 
But the mode of its entrance, and the route by which it enters, differ in 
different cases. Some contagia — such as those of syphilis, glanders, hydro- 
phobia, and vaccinia — can be introduced only by direct inoculation, effected 
by placing them in substance on some delicate mucous surface, or by in- 
serting them beneath the epidermis ; some are carried by the atmosphere, 



CONTAGION. 



139 



are inhaled, and enter through the respiratory mucous membrane ; some 
are introduced mainly with the food, and act primarily on the gastrointes- 
tinal tract. Many of the diseases which are ordinarily conveyed by the 
air, or by food, have been found to be also communicable by inoculation ; 
and it seems not improbable that, under favorable conditions, all such 
diseases might be thus imparted. 

In some of the inoculable diseases — such as syphilis and smallpox — a 
specific pimple gradually rises at the point of inoculation ; specific affection 
of the lymphatic glands next above speedily ensues; and, at or about the 
time when these have attained their full development, febrile symptoms 
supervene, to be followed in a short time by the characteristic rash. In 
vaccinia the same sequence of events takes place, with the exception that 
the febrile symptoms are not succeeded by any specific cutaneous eruption. 
In these cases, the period of the development of the primary pimple or 
pock, and of the affection of the neighboring lymphatic glands, corresponds 
accurately to the period of incubation of natural smallpox, or of other 
infectious fevers not acquired by inoculation. It is reasonable to believe 
that, what occurs in these particular affections, during the period of incu- 
bation, occurs during the same period, with some modifications of deta'l, 
in others — in other words, that specific local processes (followed by specific 
affection of the next lymphatic glands) takes place in all of them, during 
the period of incubation and preliminary to the general diffusion of the 
poison, at the spot or spots at which the virus enters the organism. It is 
not improbable that the specific lesions of diphtheria, cholera, and enteric 
fever are to be regarded as the immediate consequence of the local action 
of the specific poisons of these diseases, and as corresponding therefore to 
the syphilitic chancre, or the primary pock of inoculated variola, and not 
to the eruption of the generalized disease. 

The period of general diffusion follows; the infected lymphatic glands 
shed specific elements into the blood, with which they are distributed 
throughout the organism, to sow themselves in, or to infect, those parts of 
it which offer a suitable soil for their future development or growth. 
Various constitutional phenomena, due to the effects of the poison upon 
the blood and tissues, attend their diffusion ; but, in addition to these, 
various specific lesions of particular parts ensue, which are more or less 
characteristic for each form of disease. In many cases (the exanthemata) 
a rash appears upon the skin ; in some the tonsils, in some the salivary 
glands, in some the respiratory tract, in some the alimentary canal, in 
some certain other internal organs are mainly involved. It is obvious, 
from the above account, that the contagious matters of the contagious 
diseases must at some time or other be contained within the blood. The 
blood, indeed, in some cases and under certain conditions, is undoubtedly 
infectious. But, for the most part, this fluid rapidly purifies itself of the 
poisonous elements which enter it, discharging them mainly into those 
organs or tissues, or at those surfaces, which are the seats of the specific 
lesions of the diseases to which they belong, and which consequently be- 
come surcharged with infectious matter. 

During the progress of a contagious disease, the contagium which gave 
it origin undergoes enormous development within the organism. An in- 
conceivably minute quantity of the variolous poison, placed beneath the 
skin, results in the formation of a pock, which itself contains an infinitely 
larger amount of poison than was introduced in the first instance, and 
subsequently in the formation of thousands of pocks scattered over the 



140 



SPECIFIC FEBRILE DISEASES. 



general surface, each one of which is as fully charged with contagium as 
was the first. There can be no doubt that, in other diseases besides small- 
pox, this development of contagium goes on during the whole period of 
ingravescence — beginning at the seat of its introduction, continuing in the 
lymphatics and probably in the blood, but taking place with especial 
energy in the cutis in exanthematic diseases, and in connection generally 
with specific lesions. 

In the majority of cases the poison, which is thus manufactured within 
the organism, is discharged from it in greater or less abundance, and serves 
to propagate the disease of which it is the specific cause. This discharge, 
which occurs mainly in connection with the seats of specific lesion, takes 
place at different periods in different diseases, and necessarily also from 
different surfaces. Thus, the contagia of cholera and enteric fever are 
discharged with the alvine evacuations; those of measles, hooping cough, 
and influenza are yielded from the respiratory surface ; that of scarlet 
fever escapes probably from the throat and skin ; that of hydrophobia with 
the saliva or oral mucus; that of glanders mainly with the nasal secretion ; 
and that of syphilis with the discharges from its specific sores. 

It is very remarkable, that the majority of contagious fevers end in re- 
covery — that the poisonous matters which they engender, either die out, 
or escape from the body by one or other of the routes which have been 
numerated. This latter process has been compared to the discharge of 
urea, or other effete matters, by the emunctories. But it is obviously of 
quite a different character : for — to take smallpox as an example — there 
is not simply a discharge from the diseased surface of matters which had 
accumulated in the blood, but there is an actual manufacture of poison 
going on at each spot of disease. There arises, further, a remarkable con- 
dition of the organism, by which its susceptibility of the specific poison is 
destroyed ; for not only does the poison within it die out. but the system 
refuses to reabsorb any of the abundant poison which it manufactures, and 
remains for many years, it may be for life, free from liability to become 
again affected. 

5. Behavior of contagia external to the body. — There is a time during 
which contagia exist external to the body. How then do they comport 
themselves? It is clear that, in this respect, they present as important 
differences among themselves as they do in their influence over the body. 
The contagium of influenza is remarkable for its amazing diffusibility ; 
that of typhus clings as it were around the patient and is readily destroyed 
by atmospheric dilution ; that of scarlet fever remains dormant for months 
in articles of clothing ; that of smallpox, or of vaccinia, may be preserved 
for years between two pieces of glass, or concreted upon an ivory point. 
But the most remarkable peculiarities are presented by the contagia of 
enteric fever and cholera. In both cases, the specific poison is yielded by 
the bowel, and escapes with the feces ; and in both, probably, the poison 
is innocuous at the moment of escape, and only acquires virulent properties 
after the lapse of some time — in the case of cholera, after the lapse of four 
or five days. 

6. Nature of contagia — Having briefly considered the dependence of 
epidemic diseases on specific contagia, and the modes by which these 
poisons enter the body, act upon it, and finally get discharged from it. to- 
gether with some of their peculiarities of behavior outside the organism, 
it remains to discuss the question of their nature. In reference to this 
subject, we must not lose sight of some of the important facts with regard 



CONTAGION. 



141 



to contagion which have been adduced ; we must bear distinctly in mind, 
that the virus of one disease produces that disease only and never any 
other ; that a virus received into the body multiplies indefinitely within 
it ; that it leaves the body, not by the organs provided for the separation 
of effete matters, but by a process of efflorescence or multiplication, taking 
place in certain situations and modes, which are characteristic for each dis- 
ease ; and that external to the body it comports itself in various manners, 
of which some (as in cholera and enteric fever) evidently imply progres- 
sive developmental changes. It seems impossible that these conditions 
can be fulfilled by any element, or any combination of elements unendowed 
with life. No inorganic solid, still less any inorganic fluid or gas, no dead 
organic compound, could thus multiply itself either within or without the 
body, or thus affect the body in its progress through it. It is impossible 
to conceive of a bubble of sulphuretted hydrogen, a drop of gin, a fragment 
of marble, or a grain of morphia, multiplying itself a thousandfold within 
the system, making for its discharge some special route, and leaving the 
system thenceforth incapable of its further production. Nothing analogous 
to this has been shown to exist in the whole range of inorganic or organic 
chemistry. The facts, however, are all compatible with what we know of 
the development and behavior of organized beings, and especially of such 
as are lowest in the scale of life. We know how, when the spores of fungi 
get deposited in a suitable soil, they grow and multiply and rapidly per- 
vade it until they have exhausted it ; how, each fungus fructifies according 
to its specific character, and yields innumerable spores, which become 
widely diffused, and though retaining their specific characters and their 
vitality under apparently the most adverse circumstances, remain dormant 
until the opportunity for their development offers itself. The above, how- 
ever, is not the only argument in favor of the dependence of infectious 
fevers on living organisms. Others of still greater value remain to be ad- 
duced, (a) We know that many diseases, among which may be mentioned 
tinea tonsurans, tinea favosa, tinea versicolor, scabies, and those in which 
trichinae and hydatids are present, are actually due to the presence of ani- 
mal or vegetable parasites ; and that the behavior of the living contagia 
in these cases manifests at least as great variety as does that of the virus 
of the infectious fevers. (&) The important experiments first made by 
Chauveau, with regard to the infectious fluids of cow-pox, sheep-pox, and 
glanders, and since repeated in the case of cow-pox by Dr. Burdon Sander- 
son, show clearly, that the contagious element is not uniformly diffused 
throughout these fluids, that it does not reside either in the inflammatory 
corpuscles which they contain, or in the dissolved constituents, but in cer- 
tain minute protoplasmic particles or living bodies which, at the period of 
their chief infectiveness, they contain in great abundance, (c) 1 Specific 
parasitic growths have actually been detected in connection with several 
of the diseases in question, under circumstances which leave little doubt 
that they are the actual contagia, or specific elements, of these diseases. 
The most important observations relate to relapsing fever, and anthrax or 
the splenic fever of cattle. In relapsing fever, a form of bacterium named 
'spirillum' was first detected in the blood by Dr. Obermeier in 1872. 

1 See in relation to what follows, Dr. W. Roberts's lecture published in the 
British Medical Journal of Aug. 11, 1877 ; and Dr. Sanderson's lectures on the 'In- 
fective Processes of Diseases,' in the same journal of Dec. 1877, and Jan. and Feb. 
1878. [See also Dr. H. Vandyke Carter's ' Notes on the Spirillum Fever of Bom- 
bay, 1877,' in the Medico- Chirurgical Transactions, vol. lxi.] 



142 



SPECIFIC FEBRILE DISEASES. 



Spirilla are moving spiral filaments of extreme tenuity, and measuring 
from T gL _ to - 5 -^Q inch in length. They are found in the blood in connec- 
tion with the febrile paroxysms only — making their appearance in it shortly 
before the rise of temperature commences, and disappearing from it just 
before the occurrence of the crisis. They vary in number from day to 
day during the persistence of fever; and disappear absolutely during the 
remission. The above facts have been confirmed by many subsequent 
observers ; and recently by Dr. Heydenreich of St. Petersburg, who also 
shows experimentally that spirilla are very short-lived at febrile tempera- 
tures, and even at the normal temperature of the blood, and that there is 
good reason therefore to believe that their variable prevalence in the same 
attack is connected with the development and disappearance of successive 
generations. Eecent experiments in regard to the inoculability of relapsing 
fever tend to substantiate the belief that spirilla constitute its contagious 
element ; for the disease can be readily imparted by the blood of a patient 
in the febrile paroxysm, but not by that of the same patient during the 
apyrexial period, nor by his secretions at any time of his illness. In 
splenic fever, which is communicable only by direct contagion, and occa- 
sionally spreads in this way to man, peculiar organisms are always to be 
found in the blood, lymphatic glands, and spleen during the height of the 
disease. These are motionless, rod-like, bacteria about the -^woo °f an 
inch in length, and have been named ' bacilli anthracis.' Quite recently 
Dr. Koch of TVoolstein has performed a series of experiments which throw 
a very important light on the character and behavior of these organisms. 
He has cultivated them externally to the body, and finds, that under suit- 
able conditions they grow into branching filaments of considerable length ; 
that the filaments, which are at first structureless and transparent, after a 
time become studded with small dots; that these gradually increase in size 
until they form oval spores, which presently, on the breaking down of the 
filaments, get detached. He also finds that these spores, like all spores, 
are bodies of robust vitality and comparatively indestructible ; that under 
favorable circumstances they elongate into rods; and that under the con- 
tinuance of such circumstances the rods themselves are capable of indefinite 
multiplication by fission. He further finds that mice are highly susceptible 
of the disease; and that while disease is not imparted to them by the 
bacillus in its filamentous form, it is readily given by either spores or rods. 
Further, the spores appear always to become rods in the organism, and the 
mycelial stage is never attained there ; so that the rod-like form is the only 
one under which they seem to live parasitically. 

The arguments in favor of the dependence of the specific contagious dis- 
eases on living organisms, apart even from the remarkable series of obser- 
vations which have just been adduced, seem almost conclusive. It might 
still, however, have remained a question whether these living organisms 
were animalcules, as some have supposed, vegetables as others believe, or 
particles of the living tissues of the patient, as Dr. Beale thinks, endowed 
with specific properties. It need scarcely be said that these recent dis- 
coveries go far to give a positive solution to this question, and at the same 
time to confirm the belief of those who maintain that the specific fevers — 
in other words, their specific causes — never originate de novo. If contagia 
be lowly vegetable organisms, it is easy to understand how it is that they 
present so many characteristic differences of behavior, how it is that they 
are infectious at different periods of disease and under different circum- 
stances, and how (if like the bacillus anthracis they pass through different 



CONTAGION. 



143 



phases of living, of which some are parasitic, some non-parasitic, some in- 
fective, some innocuous) they may from time to time pass an innocent or 
dormant existence externally to the body until favoring conditions bring 
them again to active infective life — how in fact (as in cholera, plague, 
typhus, and relapsing and enteric fevers) they may, from time to time and 
under special combinations of circumstances, appear to undergo sponta- 
neous development. 

7. Septicaemia. — In connection with the subject which has just been 
discussed, as well as on account of their intrinsic importance, it seems 
desirable to call attention, however briefly, to the observations in regard 
to septicaemia which have been made during the last few years abroad, 
and by Dr. Sanderson, Prof. Lister and others in our own country. It 
seems now to be well ascertained that septic bacteria, or their invisible 
spores, are largely diffused throughout nature, but mainly in connection 
with water and watery vapor ; that they rapidly attack all organic infu- 
sions and all dead or dying animal or vegetable matters which are not 
specially protected from them ; and that they are in fact the essential 
agents in all putrefactive processes. It has also been ascertained that these 
organisms tend to breed in our bowels, and on those other mucous surfaces 
to which the air has ready access, and especially to attack external wounds 
or ulcers. And it has further been ascertained, beyond the possibility of 
doubt, that when such parts become foul and unhealthy, and their secre- 
tions fetid, these conditions are always associated with an enormous devel- 
opment of septic bacteria, which are then found mainly in the diseased 
tissues, but also in the adjoining lymphatics, and generally to some extent 
in the circulating blood. It was a natural inference, that under these cir- 
cumstances the bacteria were not only important (if not essential) agents 
in the local unhealthy processes, but that they were largely (if not solely) 
instrumental in causing the constitutional disturbance which was associated 
with them, and in the propagation of unhealthy inflammation from patient 
to patient — that they were, in fact, contagia in the sense in which we have 
hitherto employed that word. Further investigations have partly con- 
firmed, partly corrected this inference. They have confirmed it, by de- 
monstrating that the development of bacteria is essential to the production 
of the local putrefactive changes and general febrile symptoms, and to the 
communicability of the morbid process. They have corrected it, by 
proving that the bacteria (unlike true contagia) do not multiply within the 
organism, and that their injurious influence over the system, when they 
exert any, is due not to themselves, as such, but to a poison which they 
generate under certain circumstances. 

This septic poison is soluble, and can be obtained in solution, entirely 
free from bacterial or other organisms, and from putrefactive taint or ten- 
dency. It is of extreme virulence (its effects being proportionate to its 
dose), and it has exactly the same effect on the system as the material 
containing bacteria from which it is obtained. When injected into the 
tissues of the dog it gives rise to the following phenomena : the animal 
first shudders and then moves about restlessly from place to place; its gait 
becomes unsteady, and in a short time it staggers and falls on its side ; in 
the meanwhile, vomiting and violent tenesmus, followed by the discharge 
first of fecal and subsequently of mucous dejecta, take place; and then, if 
death do not ensue, the symptoms quickly subside and the animal soon 
recovers its normal appetite and liveliness. During the attack the tempe- 
rature rises gradually to about a couple of degrees above the normal, and 



144 



SPECIFIC FEBRILE DISEASES. 



then, whether recovery or death ensues, gradually falls. Immediately 
before death the fall is rapid. In fatal cases, small extravasations of blood 
are found beneath the endocardium (mainly of the left ventricle), pericar- 
dium and pleura? ; the abdominal organs generally are congested ; but the 
mucous membrane of the stomach and small intestines is hyperaemic to an 
extreme degree, and the spleen is large and infiltrated with blood. The 
blood is darker than natural, owing mainly to the fact that the red-cor- 
puscles are partially dissolved, and that their coloring matter is diffused to 
some extent through the plasma. Extreme anaemia is generally observed 
after recovery. 

The application of the above facts in explanation of the phenomena of 
septicaemia in the human being is sufficiently obvious. The symptoms of 
human septicaemia, which however is rarely uncomplicated, will be con- 
sidered further on. Meanwhile the fact that the septic poison is of local 
manufacture, and that its continued presence or its increase in the system 
is due, not to self-development in the system, but to repeated or continu- 
ous dosage, is of such supreme importance, both on scientific and on prac- 
tical grounds, that it can scarcely be impressed too strongly on the mind. 

In the above account of septic poisoning, we have insisted on the dis- 
tinction between septic bacteria and the true contagia — namely, that in 
the former the organisms undergo development in some limited area where 
they evolve a material, unliving, poison, which is thrown into the system 
and thus acts injuriously upon it, while in the latter the organisms them- 
selves enter the system, undergo development within it, and thus produce 
their characteristic effects. But while admitting the reality of the distinc- 
tion, is it, we may ask, a fundamental distinction? It can scarcely be 
supposed that the true contagia act otherwise on the body than by some 
poison which they yield or produce ; and if this be the case it can only be 
a matter of subordinate scientific importance, whether the contagia which 
evolve poison multiply within the blood as in relapsing fever, in the skin 
(mainly) as in smallpox, or in ready -formed ulcerated surfaces as in sep- 
ticaemia. These remarks not merely have reference to the organisms of sep- 
ticaemia on the one hand and the contagia of the exanthemata and continued 
fevers on the other, but they bear upon the question of the nature of the 
contagious element, in diphtheria, enteric fever, and some few other dis- 
eases, in which lowly organisms (micrococci or bacteria) have been detected 
in connection with the characteristic local lesions, but in which the rela- 
tions between these organisms and the disease have not yet been satisfac- 
torily determined. 

B. General Rules to be observed in the Management of Epidemic or 
Contagious Diseases. 

We can, as a rule, do little or nothing medicinally for the direct cure of 
the infectious fevers. So far as the patient is concerned, we can only treat 
symptoms as they arise, support his strength by suitable nourishment, 
promote the action of his excretory organs, and take precautions against 
the supervention of complications. It is, however, a most important duty 
of the medical man to prevent the spread of these diseases. The measures 
to be adopted for this end will differ to some extent, according to the cha- 
racter of the disease he has to deal with, and according to the properties 
and peculiarities of the contagium on which it depends. The following 
general rules, partly derived from ' Suggestions by the Society of Medical 



GENERAL RULES OF MANAGEMENT. 



145 



Officers of Health,' partly from other sources, may be laid down as gene- 
rally applicable : — 

1. The patient should be at once separated, as efficiently as circum- 
stances permit, from the other inmates of the house, and if possible placed 
in a top room, and have that floor devoted to him and his attendant. 

2. All bed-curtains and other hangings and carpets, and all articles of 
dress and the like in wardrobes and cupboards, and all unnecessary articles 
of furniture, should be removed thence. 

3. The room should be well ventilated ; windows should be kept partly 
open, communication with the chimney free, and if the weather or size of 
the room permit, the fire burning. The floor should be sprinkled daily 
with disinfectant fluid and cleansed. 

4. The door should be kept closed, and a sheet kept wet with a solution 
of carbolic acid, chloride of lime, or Condy's fluid, hung outside it so as to 
cover every crevice. 

5. Everything that passes from the patient (spit, vomit, urine, feces) 
should be received into vessels containing either of the above solutions ; 
and an additional quantity of solution should be added to the vessel, before 
removing it from the room and emptying it into the closet. All super- 
abundant food or drink, and all scraps, should be similarly treated, and 
under no circumstances partaken of by other persons. 

6. Pieces of rag should be used for wiping discharges from the nose or 
mouth, and burnt immediately after use. 

7. All cups, glasses, spoons, and such-like articles, used in the sick-room, 
should be placed in some disinfectant solution before leaving it, and subse- 
quently washed in hot water. 

8. All bed and body linen should at once, and before leaving the room, 
be put into a disinfectant solution. After remaining in this, for at least 
an hour, they should be boiled in water. 

9. The patient's person and bed should be kept scrupulously clean ; and 
when, during the progress of the disease, scales or crusts form upon the 
skin, their diffusion should be prevented by smearing the surface daily 
with oil. 

10. Nurses in attendance should, if possible, be such as have already 
had their patient's disease ; their dresses should be of cotton or some other 
washable material ; they should keep their hands clean, using carbolic acid 
soap, or adding Condy's fluid to the water in which they wash, and should 
as far as possible avoid inhaling the patient's breath, or other emanations 
from his person, or discharges. They should remain with the patient ; or 
if compelled to leave the room, leave it under proper precautions ; and 
under no circumstances mix with other members of the household. 

11. Visitors should not be allowed, or if allowed, should conform, as 
closely as circumstances permit, to the conditions required of the ordinary 
attendant. 

12. The medical attendant should remain no longer than necessary in 
the sick-room, and expose himself as little as possible to contamination ; 
should wash his hands before leaving ; hold as little subsequent communi- 
cation as possible with the inmates of the house ; and never go direct, or 
without proper precautions, from the infectious to other patients. 

13. The patient must not be allowed to mix with the rest of his family, 
until all peeling of the skin has ceased, or until all specific phenomena of 
disease have disappeared, and until he has been well purified by the use of 
warm baths and carbolic acid soap or Condy's fluid. Clothes used during 

10 



146 



SPECIFIC FEBRILE DISEASES. 



the time of illness, or in any way exposed to infection, must not be worn 
again until they have been properly disinfected. 

14. When the sickness has terminated, the sick-room and its contents 
should be disinfected and cleansed. This should be done in the following 
manner : Spread out, and hang upon lines, all articles of clothing or bed- 
ding ; well close the fireplace, windows, and all openings ; then take from 
a quarter to half a pound of brimstone, broken into small pieces ; put it 
into an iron dish, supported over a pail of water, and set fire to it by put- 
ting some live coals upon it ; then close the door, stopping all crevices, and 
allow the room to remain shut up for twenty-four hours. At the end of 
this time the room should be freely ventilated by opening doors, windows, 
and fireplace ; the ceiling should be whitewashed, the paper stripped from 
the walls and burnt, and the furniture and all wood and painted work 
washed with soap and water containing a little chloride of lime. Beds, 
mattresses, and other articles which cannot well be washed, should, if pos- 
sible, be submitted to a heat of from 210 to 250 degrees for two hours or 
more, in a disinfecting chamber. 

15. The house in which the patient, suffering from infectious disease, 
resides, should, during his illness, be well ventilated and kept very clean ; 
all sinks and water-closets should be in good order, and have solution of 
sulphate of iron, carbolic acid, or chloride of lime, poured into them daily ; 
dustbins should be regularly emptied, all offensive accumulations removed 
or disinfected by the free use of chloride of lime ; and all water-butts and 
cisterns kept clean and well covered. Indeed, the greatest possible care 
should be taken to prevent any kind of contamination of drinking-water. 

For the purposes of direct disinfection, many different substances may 
be employed. The following are among the more commonly useful : Sul- 
phate of iron, one pound to the gallon of water ; chloride of lime, one 
pound to the gallon ; carbolic acid (No. 4)^ a quarter of a pint to the 
gallon; Condy's red fluid diluted with fifty times its bulk of water; the 
green fluid with thirty times its bulk of water. Chloride of lime, car- 
bolic acid, and Condy's fluid are, on the whole, preferable for disinfection 
in connection with the infectious fevers. For the disinfection of linen and 
other wearing apparel, chloride of lime should be avoided on account of 
its corrosive quality. Solution of carbolic acid, or of Condy's fluid, is 
preferable. 



II. INFLUENZA. (Epidemic Catarrh.) 

Definition — A contagious, catarrhal affection of the respiratory tract, 
of short duration, but attended with much prostration, and occurring, for 
the most part, in wide-spread epidemics. 

Causation and history Influenza is one of the most mysterious, and 

at the same time one of the most interesting, diseases with which we are 
acquainted. The obscurity of its origin ; the swiftness with which it 
spreads throughout a district into which it has been introduced, and passes 
from one city to another city, from one country to another country, thus 
involving entire continents within very brief limits of time ; the shortness 
of its stay in any locality, which rarely exceeds six weeks or two months ; 
the suddenness and completeness of its disappearance ; and the irregularity 
of its epidemic visitations ; all combine to render it the most typical of all 



INFLUENZA. 



147 



epidemic diseases. Its origin and diffusion, therefore, have not unnatur- 
ally been sought for in some occult telluric, atmospheric, or electrical con- 
dition, some wide-spread morbific influence external to, and independent 
of, the frames which it affects. On the other hand, experience has shown 
that its prevalence is altogether independent of climate and season, and 
has no relation to defective drainage or other local sources of sanitary 
evils. But its conveyance has frequently been traced from locality to 
locality by the direct agency of those who are suffering from it, and its 
diffusion in fresh localities from these infected immigrants as centres. It 
is certain, therefore, that it is infectious in a very high degree, and that it 
may be imparted by a contagium, which, like other contagia, is specific, 
multiplies indefinitely in the body into which it has gained access, and is 
thence evolved in marvellous abundance. Under these circumstances it 
seems most philosophical, at all events most consonant with the present 
state of our knowledge, to reject the vague theories first adverted to, and 
to assume that the contagious influence, which certainly causes it to spread 
in large numbers of cases from man to man, affords the true explanation 
of its epidemic diffusion. The virus is doubtless given off with the breath. 
The disease has never been imparted by inoculation ; its attacks are in no 
degree determined by age or sex; and it is quite uncertain whether, or to 
what degree, one attack is protective for the future. It has been held by 
some that epidemics of influenza have a tendency to precede, or to follow, 
or to be associated with, other epidemic diseases, such as cholera. This 
relation is doubtless accidental. 

Symptoms and progress — The duration of the latent period of influenza 
has not been accurately ascertained. According to Dr. Squire it is very 
short, namely, three or four days, or at the outside a week. Its invasion 
is for the most part sudden, and marked by elevation of temperature ; 
chills, especially along the spine, sometimes amounting to rigors, and 
alternating with flushes of heat; pain, uneasiness, or a sensation of burn- 
ing in the back and limbs ; and sometimes vomiting. With these pheno- 
mena are associated, occasionally from the beginning, but more commonly 
after the lapse of some hours, severe catarrhal symptoms, indicated by dry- 
ness, redness, and swelling of the mucous membrane of the nose, sneezing, 
and, in consequence of involvement of the frontal sinuses, intense frontal 
headache; affection of the conjunctivas and pain in the eyeballs; inflam- 
mation of the fauces, larynx, trachea, and bronchial tubes to their smallest 
ramifications, with soreness of throat, hoarseness, constant hacking, often 
croupy, cough, rapidity and difficulty of breathing, and a sense of tight- 
ness or constriction of the chest. At this time the skin is generally dry, 
the tongue covered with a moist fur, the appetite lost, the pulse quickened 
and moderately full, the bowels confined, and the urine febrile ; but, above 
all, there is extreme prostration, with muscular weakness, depression of 
spirits, and precordial oppression. In the subsequent progress of the dis- 
ease, general prostration, and inflammation of the bronchial tubes, consti- 
tute its most striking features. The heat of skin now probably subsides 
somewhat ; but the patient is still apt to have alternate chills and flushes ; 
the fever assumes a remittent character ; perspirations, which are some- 
times very copious, break out ; not unfrequently sudamina appear, and 
occasionally an herpetic eruption about the lips ; the mucous membrane 
of the nose and respiratory passages begins to secrete a more or less abun- 
dant, thin, colorless mucus, which before long assumes a muco-purulent 
character ; the soreness of the throat and hoarseness probably continue ; 



148 



SPECIFIC FEBRILE DISEASES. 



the difficulty of breathing and the cough increase ; and on auscultation the 
breath-sounds are found to be feeble, or masked by sibilant and sonorous 
rhonchi and sub-crepitation ; the face gets congested or livid ; the pulse 
increases in rapidity, and loses in fulness and strength ; the tongue becomes 
more thickly coated, except perhaps at the tip and edges, and sometimes 
dry and brown ; the sickness possibly continues, and diarrhoea may come 
on ; debility grows extreme, and muscular tremors and subsultus may 
appear; the intelligence becomes markedly dull and impaired, and delirium 
is apt to supervene. Epistaxis is of common occurrence, and otitis and 
jaundice are neither of them unfrequent. 

In mild cases, the disease is at its height on the second or third day, 
and then declines gradually ; but in more severe cases — cases in which 
there is much pulmonary affection — convalescence does not commence 
until as late as the tenth or twelfth day. The patient is always much re- 
duced in strength at this time ; and convalescence is protracted in conse- 
quence, partly of persistent debility, partly of the continuance of catarrhal 
affections, or of a proclivity to catch cold. 

The most important of the complications of influenza are those arising 
out of the characteristic lesions of the air-passages: namely, laryngeal in- 
flammation, bronchitis (especially bronchitis of the smaller tubes), and 
lobular and lobar pneumonia, often associated with pleurisy. These affec- 
tions creep on insidiously during the progress of the case, and reveal 
themselves only by aggravation of the ordinary symptoms, or by the blend- 
ing of their proper symptoms with those due to the influenza itself. Gas- 
trointestinal complications also are described, and occur; but there is no 
doubt that the accidental concurrence (which is so common) of influenza 
with other diseases explains a large proportion of the cases in which it is 
found associated with these gastro-intestinal, and other less frequent, com- 
plications. 

Single cases of influenza may readily be confounded with severe catarrhal 
affections of the nose, throat, and bronchial tubes. But the high fever, 
extreme prostration, and short duration of the graver symptoms, are, all, 
important characteristics pointing to the specific nature of the disease. If 
to these peculiarities be added the fact of epidemic prevalence mistake is 
no longer possible. 

The percentage of deaths from influenza is very small, and indeed the 
uncomplicated disease is rarely fatal. Still, it attacks so large a proportion 
of a population (in some cases between a quarter and a half of the total 
number), that that small percentage does very largely augment the mor- 
tuary rate. Indeed, the prevalence of influenza has been found to swell 
the death-rate much more than the prevalence of cholera. The disease 
is chiefly fatal among the old, and such as are already suffering from 
pulmonary or cardiac affections. 

Morbid anatomy — -There is nothing distinctive in the morbid anatomy 
of influenza. Patients die chiefly of pulmonary mischief; and the evi- 
dences of this may be detected in the form of inflammation of the bronchial 
membrane, secretion into the tubes, emphysema or collapse of tissue, or 
both, or pneumonia, combined or not with pleurisy. 

Treatment — In treating influenza, it is important to adopt the hygienic 
measures which are generally useful in the treatment of infectious febrile 
affections. Medicinal treatment is not generally very efficacious. Small 
doses of nitre, alone, or combined with a few drops of laudanum, have been 
highly recommended. But probably nothing is better than a few drops 



HOOPING COUGH. 



149 



of ipecacuanha wine combined with a little laudanum, or ammonia asso- 
ciated with solution of acetate of ammonia, administered every two or 
three hours. If the bowels are confined, they may be moved either by 
mild aperients or by enemata. The inhalation of steam may relieve the 
laryngeal and bronchial affection, as also may the diffusion of moisture 
through the atmosphere of the room. The removal of blood, even by 
leeches, is rarely admissible ; still, in cases in which the congestion of the 
lungs is extreme, and death by asphyxia impending, they may be justi- 
fiably employed. Blisters again are of doubtful efficacy. Flannel or cotton 
wool, bran-poultices, or hot fomentations to the chest, on the other hand, 
are often beneficial, as also are mustard plasters. But little food will 
probably be taken, or needed, during the earlier days of the disease; and 
such as is swallowed should consist mainly or exclusively of milk, and the 
various farinacea, suspended or dissolved in milk or water. Thirst may 
be relieved by these means, or by the administration of water, tea, lemon- 
ade, soda-water, or other such drinks. Owing to the remarkable prostra- 
tion which generally is present, stimulants are for the most part soon 
required. The nature of the stimulants to be employed must depend on 
circumstances. When the patient begins to amend, tonics are indicated, 
and the diet must be gradually modified, until it combines the ordinary 
proportions of solid and fluid, and of animal and vegetable, matters which 
constitute the diet of healthy persons. The presence of complications will 
necessarily, in many cases, make some modification of treatment desirable. 
It need only be said, however, in reference to this point, that, as in the 
uncomplicated disease, so here, depletory measures generally are attended 
with risk, and very rarely called for. 



III. HOOPING COUGH. (Pertussis.) 

Definition An infectious disorder, for the most part of long duration, 

characterized by inflammation of the respiratory tract and a peculiar parox- 
ysmal cough. 

Causation Hooping cough is met with both sporadically and in an 

epidemic form, mainly attacking children, but not altogether sparing adults 
or persons of advanced age. It is said to be more common in spring and 
autumn than in other seasons ; it is probably not more common at these 
times, but attended then with a specially high mortality. Neither climate, 
nor other hygienic conditions, have any notable influence in promoting 
its spread; but epidemics of it are frequently 'associated with epidemics of 
scarlet fever or measles; and it is held by many that there is some kind 
of mysterious relation or attraction between them. It is contagious in a 
very high degree, especially during the earlier period of the disease, and 
before the whoop is established. Its contagium is given off with the breath, 
and conveyed mainly by the atmosphere ; but it is readily carried by clothes, 
and preserved in fomites. One attack confers almost complete immunity 
against subsequent attacks. 

Symptoms and progress. — As in all similar diseases, a period of latency 
intervenes between the inception of the virus and the occurrence of symp- 
toms. The duration of this period has not been accurately ascertained. 



150 



SPECIFIC FEBRILE DISEASES. 



It was exactly a fortnight in some cases which we had the opportunity of 
investigating in reference to this point. 

The invasion of hooping cough closely resembles that of an ordinary 
catarrh, and is often undistinguishable from it. There is more or less 
fever, with irritability or inflammation of the mucous membrane of the 
respiratory 'tract, and frequent cough, attended with much tickling in the 
throat and some expectoration of mucus. Some sonorous and sibilant 
rhonchus may be detected on listening to the chest, but in other respects 
the respiratory sounds are healthy. There may be injection of the con- 
junctivae, photophobia, and nasal catarrh with sneezing. The main points 
in which the disease differs thus early from ordinary catarrh are — that the 
fever is commonly higher ; that the cough is much more troublesome, 
sometimes occurring incessantly night and day, several times in the minute ; 
and that these symptoms are all much more persistent, often lasting for a 
week or fortnight without undergoing any change. 

About the end of this time the symptoms become modified; the fever 
abates, and probably soon disappears, and gradually the irritative cough 
of the period of invasion subsides, to be replaced more or less completely 
by the peculiar paroxysmal cough which characterizes the disease. Single 
paroxysms of this cough may be almost exactly simulated, especially in 
children, by the effects of the application of pepper or other irritants, to 
the laryngeal mucous membrane. But in its best-developed form, and by its 
recurrence, it is quite pathognomonic. The paroxysm is preceded by tick- 
ling in the throat, and perhaps pain beneath the sternum ; and at the same 
time a little rhonchus is probably audible on applying the ear to the chest. 
The child seems to know what is impending, becomes quiet and anxious, 
and for a short time seems to struggle against it. If lying down, it rises 
to the sitting or standing posture, and when up, clutches any firm object 
which is near, or rushes to its nurse or mother. The actual attack usually 
begins with a deep inspiration. This is at once followed by a rapid suc- 
cession of short coughs, with no intervening inspirations, which, gradually 
becoming feebler and feebler, are continued until the cavity of the chest is 
contracted to the utmost, the veins of the head and neck turgid, the face 
congested and livid, the eyes watery and starting from their sockets, the 
whole surface bathed in sweat, and asphyxia seems imminent. Then suc- 
ceeds a long, whistling, crowing, or whooping inspiration, which is pro- 
longed until the chest is once more distended with air. But the patient is 
not yet relieved ; for the cough immediately recurs ; and may be repeated 
two or three times in continuous succession until the child is utterly ex- 
hausted. During the paroxysm, which often lasts for two or three min- 
utes, and more especially at its close, a considerable quantity of viscid 
transparent mucus is discharged, and very often the contents of the stomach 
are vomited. In the attack the child may faint or become insensible ; 
the urine and even the feces may be voided ; punctiform extravasations of 
blood may occur beneath the conjunctivae, and in the skin of the eyelids 
and other parts of the face ; and there may be hemorrhage from the nose, 
and even from the air-passages and ears. The membranae tympani have 
occasionally been ruptured. The attack does not invariably begin in the 
manner above described ; for occasionally the paroxysmal cough precedes 
the long-drawn noisy inspiration ; and occasionally complete spasmodic 
closure of the glottis, followed perhaps by insensibility, replaces it alto- 
gether. After the paroxysm is over, the child remains more or less ex- 
hausted for a time : but for the most part soon resumes his amusements, 



HOOPING COUGH. 



151 



and appears to have little or nothing the matter with him. The parox- 
ysms recur at irregular intervals, and vary in number from twenty to two 
hundred (according to the severity of the case) in the course of the day and 
night, but are almost always more numerous, as well as more severe, at 
night time. In the interparoxysmal period, auscultation of the chest re- 
veals only slight indications of catarrh ; but when the patient is making 
the crowing inspiration no breath sounds whatever are audible within the 
chest. [On examining the under surface of the tongue, it is not unusual to 
find two small ulcers, situated one on each side of the frsenum. They are 
probably caused by the pressure of the tongue against the lower teeth during 
the paroxysms of coughing but are of no importance in a diagnostic point 
of view.] 

After the above symptoms have lasted with little change for several 
weeks (usually from three or four to eight or ten), the period of convales- 
cence commences. This is of very various duration, and is especially 
apt to be prolonged if the weather be inclement, if the patient be neg- 
lected, or if complications have supervened. During its continuance, the 
attacks of cough gradually decrease in number and severity, and lose their 
paroxysmal character ; the expectoration becomes thicker and opaque, and 
then ceases ; and the patient more or less rapidly regains health and 
strength. 

Attacks of hooping cough vary very much in their severity and dura- 
tion ; and just as scarlet fever, or measles may occur without the develop- 
ment of its characteristic rash, so hooping cough may pass through all 
its stages and yet its cough never be attended with the characteristic 
whoop. This is especially the case in attacks of exceptional mildness, or 
when it affects the adult. Trousseau records a case in which an attack, of 
hooping cough lasted three days only. Its entire duration may certainly 
be as short as a week or two ; but much more frequently ranges between 
six and twelve weeks. Occasionally the disease does not wholly disappear 
for six, or even twelve months. If, in the fully developed disease the 
paroxysms of cough do not exceed twenty in the four-and-twenty hours, 
the case may be regarded as a mild one. If they exceed forty or fifty, the 
case is certainly severe ; and the child is probably ill, and feverish, and 
has signs of pulmonary congestion or bronchitis in the intervals between 
them. If they are still more numerous, the danger of complications, and 
to life, is serious. Hooping cough (although one of the most common causes 
of death in children) is rarely fatal in the absence of complications. These 
are apt to come on in the second period of the disease, and especially in 
cases of great severity. They are mainly vomiting, bronchial inflammation, 
pulmonary collapse, lobular pneumonia, and emphysema, together with 
epileptiform convulsions and other forms of head-mischief. Vomiting 
chiefly attends the paroxysms of cough, and if these be frequent, innutri- 
tion, emaciation, and debility will necessarily result. The pulmonary com- 
plications reveal themselves by difficulty of breathing, lividity of face, 
crepitation and sibilant rhonchus (without any necessary dulness on per- 
cussion of the chest), increased frequency of pulse, and rapid impairment 
of strength. The emphysema of the lungs, which is the result of lacera- 
tion of the air-cells, is in children often interlobular, and occasionally 
spreads through the root of the lung to the connective tissue of the neck, 
face, and chest. Convulsions occur, chiefly in infants who are teething, 
and may be either ordinary attacks of eclampsia, or attacks resembling 
those of laryngismus stridulus in which respiration is arrested by spasmodic 



152 



SPECIFIC FEBRILE DISEASES. 



closure of the glottis — insensibility supervening, attended with convulsive 
movements of the muscles of the face and eyes. These complications are, 
no doubt, serious, and the latter especially may be suddenly fatal, yet the 
great majority of children who experience them recover perfectly. Dr. E. 
Smith has shown, that hooping cough is the most fatal of all the diseases 
of children under one year of age, that sixty-eight per cent, of all the deaths 
from it occur under two years of age, and only six per cent, above the age 
of five years. 

Morbid anatomy. — The lesions observed after death from hooping cough 
are always those of its complications : — namely, congestion of the mucous 
membrane of the larynx and other air-passages, with secretion into the 
bronchial tubes, collapse of lung-tissue in patches, lobular pneumonia, 
emphysema, and in children interlobular emphysema. Post-mortem 
examination, indeed, throws no light whatever on the nature of the disease. 
Congestions of the medulla oblongata, and of the pneumogastric nerves, 
which have been described as occurring in hooping cough, are probably 
purely accidental conditions, if not the result of mere post-mortem changes. 
So again, enlargement of the bronchial glands, which has been frequently 
observed, has no necessary connection with it. It has been much discussed, 
whether the disease is essentially nervous, or a mere inflammatory condition 
of the respiratory mucous membrane. It seems probable, however, that it is 
not exactly either one or the other ; but that, like other infectious fevers, it is 
the result of a virus, which affects more or less the whole system, but has 
a special tendency to involve the respiratory mucous membrane, produc- 
ing in it a slight but specific inflammatory change, to the effect of which 
on the peripheral ends of the pneumogastric nerves the cough, with its 
peculiar characteristics, is due. This view is confirmed by the fact that 
it is evidently from the implicated mucous surface that the contagium of 
the disease is chiefly, if not exclusively, emitted. 

Treatment As is the case with all diseases of uncertain duration and 

of intractability, many specifics have been vaunted for the successful treat- 
ment of hooping cough. Among the more important of these are hydro- 
cyanic acid and belladonna. With respect to the latter remedy, Trous- 
seau strongly urges that it should be given in one dose daily — and that in 
the morning on an empty stomach ; and that, if an increase be necessary, 
it should be by augmentation of the morning's dose. For infants under 
four he recommends, to begin with, a pill made with -jL gr. of the ex- 
tract and T L gr. of the powdered leaves, or gr. of the neutral sulphate 
of atropia. If hydrocyanic acid be preferred, from one to two minims of 
the dilute preparation may (according to Dr. Roe) be given to young chil- 
dren every three or four hours. Strychnia, hyoscyamus, conium, arsenic, 
iron, bromide of potassium, and bromide of ammonium, have also been 
strongly recommended, as also have alum, tannin, and the mineral acids. 
But it is almost certain that no drug has any direct influence over the 
course of disease ; and that hence our efforts must be directed to the relief 
of distressing symptoms, to the prevention of complications, and to the 
maintenance of the patient's strength. To these ends it is important that 
he be kept to his room, which, though well ventilated, should be main- 
tained of uniform temperature ; that, if not confined to bed, he be clothed 
in flannel ; and, generally, that he be not exposed to draughts, or condi- 
tions liable to cause pulmonary inflammations. For medicine, there is 
probably nothing better than a combination of a few drops of ipecacuanha 
wine with a minute proportion of laudanum or belladonna, to be admin- 



MUMPS. 



153 



istered every two, three, or four hours. Counter-irritants are sometimes 
useful ; and the application of a strong solution of nitrate of silver to the 
larynx has been much recommended, especially by Bouchut and Eben 
Watson. The patient's diet must be regulated according to circumstances ; 
but generally it should be plain, wholesome, aud nutritious. In the period 
of convalescence, tonics, and change of air, or, failing this, daily exercise 
in the open air, are advisable. When complications arise they must of 
course be treated specially. But they need no treatment distinct from that 
of the same affections occurring under other circumstances. 



IV. MUMPS. {Parotitis.) 

Definition. — A contagious fever, of which the chief characteristic phe- 
nomenon is inflammation of the salivary glands. 

Causation Mumps, like scarlet fever, measles and hooping cough, is a 

malady which is generally present amongst us, in a greater or less degree, 
and every now and then assumes an epidemic character. Like them, 
moreover, it is extremely infectious, infects, as a rule, but once in a life- 
time, and may be regarded as mainly a disease of childhood. It is not, 
however, confined to childhood ; and unprotected adults, and even persons 
of advanced age, may suffer from it. It is probably not influenced by sex ; 
and there is no reason to believe that its prevalence depends, in any 
degree, on season, weather, or climate. The virus of mumps seems to be 
contained principally, if not solely, in the breath. 

Symptoms and progress. — The incubative period of mumps doubtless 
varies ; many cases, however, have been recorded in which it seems to 
have been fourteen days ; and this may be taken as probably its average 
duration. The invasion of the disease is sometimes indicated by febrile 
symptoms and headache, on which, after a few hours or a day or two, 
parotid inflammation supervenes ; but, in many cases, the affection of the 
parotid gland precedes the febrile phenomena, or accompanies them from 
the first. The patient usually complains of aching and tenderness behind 
one of the ascending rami of the lower jaw ; and, in a short time, a little 
fulness is perceived there, completely obliterating the groove normally ex- 
isting in that situation. But occasionally the inflammation begins in that 
part of the parotid which lies upon the masseter muscle. The aching, 
tenderness, and swelling gradually increase for three or four days, until 
the whole of the parotid region is occupied by a dense elastic tumor, which 
extends forwards over the masseter muscle, and downwards below the 
angle of the jaw, and over which the skin may assume a rosy hue. Some- 
times, the inflammation remains limited to one parotid gland ; but more 
frequently, it involves both parotids, and both submaxillary glands as well, 
attacking them successively at short intervals, so that all become impli- 
cated in the course of two or three days. The inflammation spreads also 
to surrounding parts, and especially to the fauces and tonsils. When the 
affection embraces all the glands, and is fully developed, the swelling 
(which then involves the parotidean and inferior maxillary regions of both 
sides) marvellously alters the character of the face, giving to its sides great 
fulness and breadth, and adding beneath a large double chin. The gland- 
ular affection generally reaches its full development in from three to six 



154 



SPECIFIC FEBRILE DISEASES. 



days, and remains stationary for a day or two longer. During the whole 
of this period the swollen parts are firm and tense, very tender on pressure, 
and attended with much aching, which becomes exceedingly severe when 
the jaw is moved, and even when the act of deglutition is performed. 
Hence the patient cannot masticate, and has much difficulty in swallowing, 
and the saliva tends to accumulate in his mouth. The febrile symptoms 
moreover continue — the temperature sometimes attaining a height of 103° 
or 104° ; and there is more or less thirst and anorexia. The character 
of the saliva, and its quantity, are not usually altered, at all events not 
altered materially. After a time, which varies according to the severity 
of the case, and rarely exceeds a week, the swelling of the glands begins 
to subside, and therewith all the general symptoms. The whole duration 
of the illness may be a week, but more frequently extends to ten or twelve 
day? or a fortnight ; but even at the end of that time, the shrunken sub- 
maxillary glands may often still be felt of almost stony hardness. Occa- 
sionally the skin over the swollen regions desquamates. 

It sometimes happens in the course of mumps (generally in the period 
of its decline, and occasionally after it has apparently disappeared), that 
in the male one or both of the testicles get enlarged and painful, and in 
the female inflammatory swelling of the mammre or labia comes on. 
These complications supervene generally without warning, but at times 
are preceded by apparently unaccountable symptoms of the most alarming 
kind — sometimes severe collapse, sometimes high fever with delirium. 
They subside in the course of a few days. Atrophy of the testicle occa- 
sionally follows. 

Mumps is a disease of little gravity, and rarely, if ever, terminates 
in death. But it is apt to leave behind it a good deal of feebleness of 
health. It is most likely to be confounded with non-specific inflamma- 
tion of the parotid, and inflammatory enlargement of the cervical lym- 
phatic glands ; but, under any circumstances, the confusion can only be 
temporary. 

Morbid anatomy So little opportunity is afforded of investigating the 

morbid anatomy of mumps that little can be said positively on the subject. 
The salivary gland inflammation probably differs anatomically in no respect 
from that arising from other causes, but it never proceeds to suppuration. 
There is doubtless considerable infiltration of the connective tissue of the 
glands ; and indeed the infiltration extends beyond the limits of these 
organs, involving more or less of the subcutaneous connective tissue on the 
one hand, and that of the fauces on the other. 

Treatment Persons suffering from mumps should be kept out of 

draughts, and, if not confined to the bed or sofa, at least debarred from 
making active exertion. The swollen parts may be relieved by fomenta- 
tions, or the application of flannel or cotton-wool. The bowels may be 
kept slightly open. The patient should be fed, during the ingravescence 
of the disease, on milk, bread and milk, eggs, and other like foods, which 
need no mastication. When alarming symptoms show themselves, ammo- 
nia and other stimulants are indicated. 



MEASLES. 



155 



V. MEASLES. {Rubeola. Morbilli.) 

Definition. — A contagious exanthem, characterized by the presence of 
catarrh of the respiratory mucous membrane, and a peculiar eruption, 
coming out on the fourth day. The disease usually lasts between one and 
two weeks. 

Causation— Measles is one of the most virulently contagious of dis- 
eases ; and, although its virus can probably not be so long preserved in an 
active form by fomites, or in other ways, as the contagia of scarlet fever 
and smallpox, the presence of a case of measles amongst a number of un- 
protected persons will, as a rule, induce a more certain and widespread 
outbreak of disease than either of the other exanthems would do under 
similar circumstances. This peculiarity is due, in some measure, to the 
fact, that its contagiousness is fully developed at a very early stage — being 
at its height on the second, if not the first, day of invasion, and conse- 
quently before the specific nature of the attack is revealed. Hence the 
great difficulty, if not impossibility, of effectually preventing its spread in 
households and schools. Measles is generally present in a sporadic form, 
but at irregular intervals assumes an epidemic character, spreading rapidly 
amongst those who have not yet suffered from it, and subsiding when its 
pabulum gets exhausted. It is mainly a disease of childhood ; not, how- 
ever, so much because adults are naturally iryjisposed to take it, as because 
from its constant presence amongst us and its extreme contagiousness, 
almost all persons have it early in life, and are thus protected from subse- 
quent attacks. In exceptional cases, the same individual takes it a second 
and even a third time ; and occasionally the second attack follows so 
quickly on the first that it constitutes a relapse. This proclivity to re- 
peated seizures occasionally runs in families. In the great majority of 
cases, however, one attack is permanently protective. 

Symptoms and progress The latent period of measles varies like that 

of all other similar diseases ; its extreme limits are probably seven and 
twenty-one days. When the disease has been given by inoculation with 
the nasal mucus, the first symptoms are said to have manifested themselves 
on the seventh or eighth day. But when it is caught, in the usual way, 
by inhalation of the virus, the incubative period is generally from twelve 
to fourteen days. 

During this time the patient, with rare exceptions, is apparently in 
good health ; but occasionally he surfers from lassitude, debility, and slight 
febrile disturbance. The invasion of the disease is marked by catarrhal 
symptoms, in association with slight fever. Chills or slight rigors occur, - 
with elevation of temperature and acceleration of pulse ; and, at the same 
time, the mucous membrane of the nose gets injected and irritable, and 
secretes a thin mucus, and there is frequent sneezing and sometimes epis- 
taxis. The catarrhal affection speedily extends to the frontal sinuses, 
causing frontal headache ; to the eyes, causing congestion of the conjunc- 
tivas, watering, and intolerance of light ; to the fauces and mouth, induc- 
ing patchy redness ; and to the larynx, trachea, and bronchial tubes, 
causing soreness, hoarseness, and a hacking cough. Occasionally, in 
children, the disease is ushered in with an epileptiform convulsion, or 
several such convulsions ; and, on the other hand, not unfrequently the 
initiatory symptoms are so slight as to escape observation. During the 
period of invasion, the skin is mostly dry, though sweating may come on 



156 



SPECIFIC FEBRILE DISEASES. 



from time to time, especially after the rigors ; the tongue remains natural 
or becomes somewhat furred ; there is loss of appetite, sometimes sickness 
and thirst, swimming in the head, and occasionally on the third day some 
remission of symptoms. 

On the fourth day (inclusive) after invasion — sometimes a little earlier, 
sometimes later — the catarrhal symptoms and fever become aggravated, 
the temperature rises, the pulse quickens, the patient gets dull and perhaps 
a little confused, diarrhoea sometimes comes on, and the characteristic 
eruption begins to appear. This first shows itself on the forehead and 
temples, near their junction with the hairy scalp, on the cheeks, chin, and 
back of the neck, whence it gradually diffuses itself over the general sur- 
face from above downwards, invading first the chest and arms, then the 
abdomen and legs. Hands and feet are both affected. It usually becomes 
most developed on the back of the trunk, and probably least on the gene- 
rative organs and neighboring portions of the abdomen. The rash gener- 
ally attains its height in a couple of days (on the sixth day of the disease), 
sometimes in three or four, and then declines in the order of its appear- 
ance. Its subsidence is followed, in ten days or a fortnight, by a very fine 
scurfy desquamation, which is chiefly observable about the forehead and 
cheeks. The severity of the symptoms continues to increase so long as 
the rash itself increases ; and, with the height of the eruption, the tem- 
perature attains its highest point, which rarely exceeds 103° or 104°. 
When, however, the eruption begins to fade (namely on the sixth day, or 
it may be a little earlier or later) the temperature almost suddenly falls 
several degrees, the severe symptoms subside, and convalescence com- 
mences. The temperature in some cases at once sinks to the normal, 
but more frequently it descends to 101° or 100°, at which elevation it 
remains for a day or two, and then reaches the normal limit, or even sinks 
below it. 

The catarrh of measles is very characteristic and important. It usually 
commences in the nose, and extends as has been already described. In 
favorable cases, it involves simply the discomforts of ordinary catarrh. 
But not unfrequently it assumes a more serious, character : sometimes it 
induces inflammation of the eyes, which may. terminate in chronic or in 
purulent ophthalmia, and even in their destruction ; not unfrequently it 
reaches the tympanum, through the Eustachian tube, causing more or less 
intense earache and deafness, upon which suppuration of the middle ear 
or permanent deafness may supervene. Very often croupy symptoms 
manifest themselves, or acute bronchial catarrh, or capillary bronchitis. 

The tongue is sometimes clean, sometimes covered with a w T hitey-brown 
fur, but does not usually get dry. Occasionally, however, when typhoid 
symptoms manifest themselves, it becomes both dry and black, and sordes 
appear on the teeth and lips. There may generally be seen, early in the 
disease and before the appearance of the cutaneous eruption, spotty red- 
ness of the palate and fauces, of the inner surface of the cheeks and lips, 
and of the gums. This often gets uniform and intense, especially on the 
gums and at the back of the mouth, and is sometimes attended later on in 
the disease with aphthae or excoriation, and ulceration of the gums. Gan- 
grene of the mouth is met with in rare cases. Sickness is by no means a 
constant symptom, and seldom lasts beyond the period of invasion. Diar- 
rhoea frequently comes on with the eruption, and is often very troublesome. 
Sometimes late in the disease it assumes a dysenteric character. 

The urine is scanty and somewhat high-colored, and often deposits a 



MEASLES. 



157 



sediment of urates. Albumen is occasionally present in it during the 
height of the fever. 

The eruption on its first appearance has a dusky pink color ; it consists 
of small slightly-elevated papules, which gradually increase in area until 
they attain a line or even two lines in diameter. They are darkest at the 
centre and fade towards the periphery, and are momentarily effaced by 
pressure. They are at first discrete, although arranged in groups which 
have a tendency to form irregular crescents or circles. When they have 
attained their full size, however, neighboring spots often run together ; 
and sometimes, where the rash is very thick, an extensive area of nearly 
uniform redness results. Whilst the eruption is well-marked, there is 
always more or less subcutaneous infiltration, and the face appears swollen, 
and the hands and feet feel tight and uncomfortable. The spots fade very 
quickly ; but, for the most part, there remains some pigmentary discolor- 
ation, and perhaps, too, some slight tendency in the vessels of the affected 
spots to dilate under excitement, which collectively render indications of 
the rash visible long after the actual rash has disappeared. The skin is 
generally hot and dry. Gangrene of the vulva occasionally occurs in 
young children. 

The presence of frontal headache has already been adverted to. The 
chief other pains to which patients are liable are those connected with the 
occurrence of diarrhoea or dysentery, and otitis. If young children seem 
to be in severe and continuous pain, the latter complication may be sus- 
pected. Patients, especially children, are somewhat dull and irritable, 
and occasionally, during the early period of the eruptive stage, slightly 
delirious. Marked delirium is unusual, except in severe cases, and cases 
assuming a typhoid character. In the latter, coma sometimes supervenes, 
and sometimes convulsions. Convulsions in the eruptive stage are far 
more serious than those occurring during the period of invasion. 

Measles, if unattended with any serious complication, is commonly a 
mild disorder, convalescence from which commences about the sixth day, 
and is completed by about the tenth. Sometimes it is so slightly developed, 
that its presence is only indicated by slight feverishness and fretfulness, 
and an inconspicuous rash about the cheeks and back of the neck, asso- 
ciated or not with catarrhal symptoms. In such cases the patient may be 
well within three or four days from the first manifestation of symptoms ; 
and it may be impossible by these alone to recognize his disease. Some- 
times the attack of measles is inherently very severe ; and such severity 
of attack occasionally characterizes epidemics. In this case, the patient 
manifests obvious prostration from the beginning ; the pulse is rapid and 
feeble; the eruption is scanty and of a dusky hue, sometimes almost black, - 
or petechial ; the lungs get congested ; typhoid symptoms, characterized 
by black tongue, tremulousness, and delirium, soon come on; and the 
patient dies collapsed, perhaps comatose, at an early period. [Without 
necessarily assuming a typhoid character, an attack of measles is apt to 
occasion much more serious illness in an adult than in a child. Not only 
is the eruption tardy in making its appearance, but it occupies more time 
in extending to all parts of the body ; the patient meanwhile suffering from 
excessive irritability of the stomach, headache, insomnia, and other distress- 
ing symptoms. During the recent civil war in America numbers of young 
recruits from country districts fell victims to this disease.] When the 
crisis is delayed beyond the sixth or eighth day, the cause of the delay is 
generally the supervention, or aggravation, of one of the ordinary compli- 



158 



SPECIFIC FEBRILE DISEASES. 



cations of the disease, especially laryngitis, bronchitis, lobular pneumonia, 
or pneumonia. These in fact constitute the main causes of the unfavorable 
results of measles. Death, however, may ensue from any of the other 
complications which have been enumerated — diarrhoea, dysentery, epistaxis, 
gangrene of the mouth or other parts, or the results of otorrhoea. Pul- 
monary phthisis appears to be a not unfrequent sequela of measles, follow- 
ing upon the more common pulmonary or bronchial inflammation. Diar- 
rhoea of a very persistent and troublesome character often comes on after 
measles in children. 

Morbid anatomy — Internal organs manifest no post-mortem appearance 
peculiar to measles. If the patient die early, or of the malignant form of 
the disease, the blood is dark-colored and coagulates imperfectly, and there 
may be hypostatic congestion of the lungs and congestion of other organs. 
Later on, we necessarily detect the lesions which have been instrumental 
in causing death — lesions chiefly of the air-passages and lungs, or bowels. 

Treatment The patient, for the sake partly of counteracting spread, 

partly of preventing aggravation of the various mucous inflammations by 
exposure to cold, should be confined to his room, and, if possible, kept in 
bed until febrile symptoms have entirely subsided. His room should be 
airy and well-ventilated, but of an agreeable temperature ; and he should 
be carefully protected from draughts or chills. It is not generally neces- 
sary that medicines should be given ; but, partly to promote the excretions, 
and partly to relieve the irritation of the respiratory mucous surface, a 
mixture, containing a small quantity of ammonia with the acetate of am- 
monia, to which may be added ipecacuanha wine and minute doses of 
laudanum (very minute in cases of young children), may be frequently 
administered ; for the soreness of the throat, a little black currant jelly 
may be used, and the patient may gargle with warm milk. In consequence 
of the tendency to dysenteric diarrhoea, purgatives should be avoided, or 
employed with great caution. The diet should be mainly bread and milk, 
beef-tea, and other such fluid, bland, nutritious articles of diet. When 
convalescence is in progress, vegetable tonics are useful, and a substantial 
diet must be gradually adopted. The various complications of the disease, 
and its sequelse, will require each its appropriate treatment, which need 
not differ materially from that of the same affection occurring indepen- 
dently : only it is important to recollect that depletory measures are in 
this case specially injurious. When the eruption is dusky, or comes out 
imperfectly, and the patient at the same time appears to be very ill, a 
warm bath is often of great service. It may also prove beneficial when, 
late in the disease, convulsions come on. When the patient shows signs 
of exhaustion, and especially therefore in the malignant form of the dis- 
ease, and when typhoid symptoms are present, stimulants are imperative. 
In most cases of measles they are quite unnecessary. ' 



VI. EPIDEMIC ROSEOLA. (Rotheln. Rubeola.) 

Definition — A contagious disorder, having a close resemblance to 
measles, with which it is often confounded. 

Causation — This disease is said to occur chiefly in hot seasons, and to 
affect children much more readily than adults; it is doubtful, how r ever, 



EPIDEMIC ROSEOLA. 



159 



whether season or age exerts any special influence over it. It certainly 
spreads by contagion, and doubtless, therefore, depends on a specific virus. 
Its contagiousness is apparently much less active than that of measles. 

Symptoms and progress. — The incubative period of epidemic roseola 
is probably about a week. Its invasion, in a considerable number of cases, 
is coincident with the appearance of the rash. In some cases, however, 
the eruptive period is preceded by a day or two of poorliness; the patient 
has a headache or is feverish, and may even have rigors ; or he complains 
of cold or catarrh, and according to Trousseau, may, if a child, have 
diarrhoea and convulsions. The latter occurrences, however, must be very 
rare ; and, indeed, among the chief distinctions between this affection and 
measles are the slightness, the want of character, and the uncertain but 
always short duration, of its stage of premonitory fever. 

The rash generally appears first on the sides of the nose and adjoining 
parts of the cheeks, the lower region of the forehead, and the lateral aspects 
of the inferior maxilla ; but it shows itself almost, if not quite, as early on 
the forearms and hands, and corresponding parts of the lower extremities, 
and then rapidly diffuses itself over the whole cutaneous surface. It usu- 
ally attains its height on the second day, and, in the course of the next 
two, three, or four days, rapidly disappears. The rash has much resem- 
blance, in tint and general appearance, to that of measles: but it does not 
assume the crescentic grouping which is characteristic of that affection. 
The spots, which fade on pressure, are of a dusky red or purplish hue, of 
irregular shape and often clustered — sometimes running together over 
considerable tracts — and vary in size from mere points up to a line or 
more in diameter. They are, for the most part, scarcely elevated above 
the general level of the skin ; but occasionally, and more especially on the 
face, form considerable papular or tabular elevations. The rash is gene- 
rally most abundant on the face, where it is often confluent, and on the 
forearms and legs (especially about the ankles and wrists), where also 
there is often a similar tendency to confluence. It is less thickly developed 
elsewhere; but no part is free; and generally, abundant discrete spots 
may be observed on both the palmar and the dorsal aspects of the hands 
and fingers, and on the corresponding parts of the feet and toes. It is 
attended with considerable itching, and is often followed by branny des- 
quamation. The patient does not generally complain much, or at all, of 
soreness of the eyes or lachrymation ; nevertheless there is nearly always 
marked congestion of the conjunctivae. There is frequently a little sore 
throat; and sometimes red puncta, or more or less diffused redness, may 
be recognized on the soft palate and fauces. There is not, as a rule, de- 
fluxion from the nose or sneezing, or, if these symptoms are present at all, 
they are by no means prominent. There is often a little cough. During 
the first day or two after the appearance of the rash, the patient may be 
somewhat feverish, with slightly elevated temperature, headache, or swim- 
ming in the head, and other slight symptoms referable to fever; but not 
unfrequently he feels and expresses himself as being perfectly well. The 
affection is unattended* with complications, subsides ordinarily within a 
week, and has no sequelae. 

Epidemic roseola has been described as a hybrid of scarlet fever and 
measles ; and some have regarded it literally as such. There is little like- 
ness, however, between it and scarlet fever. Its resemblance to measles, 
on the other hand, is very close. It differs from measles, chiefly in the 
slight development of its initiatory fever, in the almost complete absence 



160 



SPECIFIC FEBRILE DISEASES. 



of coryza, in the arrangement of its eruption, and in the general mildness 
of its symptoms ; but these differences are chiefly of degree, and only such 
as might be observed between very slight and severe cases of true measles. 
The main distinctions are these — that roseola and measles are mutually 
unprotective; that roseola is of frequent occurrence in those who have had 
measles only a short time previously; and that when it breaks out in a 
family or school of children, of whom some have had measles and some 
not, it attacks them indiscriminately and with equal mildness, and never 
gets developed into true measles. 
No special treatment is needed. 



VII. SCARLET FEVER. {Scarlatina. Febris Rubra.) 

Definition A contagious malady, characterized mainly by a general 

punctiform scarlet eruption, usually appearing on the second day, and by 
inflammation of the fauces, tonsils and kidneys. 

Causation and history Down to the sixteenth or seventeenth century 

scarlet fever was confounded with measles. Yet they are two perfectly 
distinct diseases, and are now fully recognized as distinct. Whatever its 
original source, or however it may formerly have been limited in area, it 
is now general throughout the world, occurring in most parts sporadically, 
but frequently breaking out into epidemics of greater or less severity. Its 
prevalence seems independent of season or climate, but, as with other 
infectious epidemic disorders, is largely promoted by overcrowding and 
poverty. Children suffer from it in much larger proportion than adults ; 
not, however, because there is any special proclivity to it in childhood ; 
but because, from its frequent prevalence and highly infectious nature, the 
great majority of children are exposed to its influence during the first few 
years of life, contract it and thus acquire protection. Scarlet fever rarely 
occurs a second time ; yet second and even third attacks have been noticed. 
It is a common observation, however, that protected attendants on scarla- 
tinal patients frequently suffer from sore throat during the period of their 
attendance; and the question naturally arises, whether such attacks should 
not be regarded as abortive attacks of scarlet fever. They probably are 
so. The contagion of scarlet fever is very powerful and diffusive. It may 
be carried considerable distances by the atmosphere — certainly through 
the whole dimensions of a large ward ; and it clings to clothes and other 
fomites with great tenacity, and may thus lie latent yet capable of action 
for an indefinite period. Scarlet fever occurs only as the result of con- 
tagion, usually conveyed by the means which have been already indicated. 
It seems that it may also be transmitted by direct inoculation. For there 
is reason to believe that it can be imparted by inserting the fluid of the 
scarlatinal vesicles beneath the cuticle of persons who have not yet had it ; 
and it is certain that women, at the time of parturition, are specially liable 
to take it, receiving it then, in some cases, apparently direct from the 
fingers of the accoucheur. The time at which a scarlatinal patient begins 
to be infectious is uncertain. We know, however, that his infectiousness 
is not very well marked during the first two or three days. It probably 
increases with the development of the rash and sore throat, and pretty 
certainly does not cease until desquamation has been completed. 



SCARLET FEVER. 



161 



Symptoms and progress — The incubation of scarlet fever is shorter 
than that of most diseases of the same class. It usually varies between 
six and eight days, but is occasionally longer, and very often less. Many 
cases, indeed, of undoubted authenticity have been recorded, in which it 
certainly did not exceed twenty-four hours. Especially in puerperal 
women, and probably also in persons suffering from large wounds, the 
period of latency seems generally to be of very short duration. Scarlet 
fever varies, perhaps more than any other like disease, both in the degree 
of severity of its attacks, in the symptoms which it presents, and (in fatal 
cases) in the cause and period of death. In a typical case, the invasion 
is sudden, and usually marked by chills, vomiting, and sore throat ; with 
which are associated, or on which soon supervene, great rise of tempera- 
ture, general dryness of skin, much acceleration of pulse, langour, drowsi- 
ness, frontal headache, giddiness, aching in the limbs, slight coating of 
tongue, thirst, anorexia, and sometimes diarrhoea. The most characteristic 
of these symptoms are — the sore throat and vomiting ; the remarkable 
rise in the frequency of the pulse, which may attain 120 in the adult or 
160 in the child; and the rapid augmentation of temperature, which may 
reach very nearly 105° during the first day. The disease is sometimes 
ushered in with rigors, and not unfrequently there is some delirium or 
even tendency to coma. 

On the second day the rash makes its appearance, first on the chest, 
and simultaneously or very soon afterwards on the forearms, lower part of 
the abdomen, and upper part of the thighs. It becomes general in the 
course of four-and-twenty hours, more or less, and attains its full devel- 
opment on the third or fourth day. It consists, in the first instance, of 
very minute, rosy papules, due for the most part (as those of so-called 
< goose's skin') to the conical elevation of the cutis around the points of 
emergence of the hairs ; hence they are closely and pretty uniformly ar- 
ranged, but discrete and separated from one another by healthy skin. But 
they soon increase in size and intensity of redness, and presently, blending 
with one another by their congested margins, give to the surface a uni- 
formly scarlet hue. The papular character, however, of the rash is still, 
for the most part, distinguishable on close inspection. Not unfrequently 
the papulae on the chest and sides of the neck become vesicular ; and gener- 
ally the rash is attended with more or less infiltration and thickening of 
the cutis. The vivid redness of the skin disappears readily on pressure, 
as by drawing the point of the nail firmly along the surface ; and the line 
thus formed remains anaemic for a second or two. The scarlatinal rash 
varies much in its intensity and in its diffusion. It is sometimes very 
pale and almost imperceptible ; and it may be strictly limited to the parts 
in which it usually first appears. When general, it is most vivid on the 
neck, chest, abdomen, and inner aspects of the thighs and arms. It is 
rarely distinct upon the face, which, however, often presents irregular 
patches of redness. The feet and hands are not unfrequently stiff with 
it, and its attendant oedema. t 

While the rash is attaining its full development, the other symptoms 
are all undergoing aggravation : — The heat rises ; the pulse increases in 
frequency ; the respirations grow more rapid ; the tongue, which was at 
first covered (excepting at the tip and edges) with a thickish whitey- 
brown fur, soon cleans, and towards the end (that is in four or five days 
from the invasion) becomes morbidly red, with swollen papillae, and pre- 
sents the remarkable strawberry-like appearance so characteristic of this 
11 



162 



SPECIFIC FEBRILE DISEASES. 



disease. At this time too it is apt to get dry. The soreness of the throat 
increases; and, on inspection, more or less livid or dusky redness of the 
pillars of the fauces, soft palate, uvula, and tonsils, is apparent. These 
parts, moreover, swell : and the tonsils often enlarge as in common quinsy, 
and present here and there on their surface imbedded, or adherent, spots 
of inspissated secretion. With the faucial swelling and inflammation are 
usually associated pain and difficulty in swallowing, fulness and tenderness 
behind the angles of the jaw, and some enlargement of the neighboring 
lymphatic glands. The patient's muscular weakness increases, and his 
limbs get tremulous ; he becomes and looks dull and stupid, or restless, is 
forgetful and slow to answer ; delirium probably increases ; vomiting is 
now not common, but thirst and anorexia continue ; and the bowels, though 
variable, are generally constipated. 

From the fourth to the sixth day of the disease, the rash begins to fade; 
and it disappears, according to its intensity and the date at which it at- 
tained its maximum, between the sixth and twelfth day of the disease, or 
between the fifth and tenth day from the comencement of the rash. It is 
frequently about this time that, if the case be going on badly, the patient 
passes into a typhoid condition, or throat complications become serious — 
the tonsils suppurating, ulcerating, or sloughing — or the urine gets albu- 
minous, and anasarca and uraemia supervene. If, however, the case be 
going on favorably, all the symptoms now gradually subside: the tempe- 
rature, with slight daily remissions, ere long becomes normal or even sub- 
normal ; the pulse by degrees sinks to its healthy rate or below it ; the 
soreness and inflammation of the throat subside ; the tongue gets clean 
and moist ; thirst abates ; appetite returns ; and delirium, with other symp- 
toms referable to the nervous system, vanishes. 

With the disappearance of the rash, desquamation commences. It may 
be observed, indeed, on the chest before the rash has quite left other parts 
of the surface. It usually begins on the neck and chest ; whence it spreads 
to the rest of the trunk, and then to the limbs, involving lastly the palms 
of the hands and soles of the feet. Desquamation always takes place in 
considerable flakes, the size of which is greater according as the epidermis 
is thicker. Hence, they are small and delicate on the chest and abdomen, 
large on the limbs ; and from the hands and feet the epidermis occasionally 
separates in the form of a glove. The period of desquamation is of very 
various duration ; it is sometimes completed in one or two days, not unfre- 
quently extends over a week or two, and occasionally is prolonged for seve- 
ral weeks. It is a period of some danger ; for it is chiefly then that albu- 
minuria arises, that dropsy and uraemia threaten, and that rheumatism and 
other serious sequelae are liable to come on ; moreover, there is good reason 
to believe that the desquamating particles of skin are charged with the 
contagium of the disease, and are highly infectious. 

We will now pass briefly in review some of the more important pheno- 
mena of scarlet fever. Acceleration of the pulse, especially in children, 
is a notable feature of the disease ; it probably rises on the first day to be- 
tween 100 and 120 — in children still higher; and it generally continues 
to increase up to the time of full development of the rash, sometimes attain- 
ing a rate of from 120 to 160, or more ; after which, if the case go on 
favorably, it gradually falls. This great acceleration of pulse is not neces- 
sarily an indication of danger. Nevertheless, unusual rapidity with marked 
weakness of pulse, especially when associated with other unfavorable symp- 
toms, is of grave import. 



SCARLET FEVER. 



163 



Respiration is always more or less hurried, but there is not necessarily 
any cough or difficulty of breathing. Sometimes, however, in cases of 
great intensity (as also in pyaemia and other forms of so-called i blood 
poisoning') the respirations become very rapid and shallow, and the inspi- 
rations attended with dilatation of the nostrils, and a sniffing or sucking 
sound — conditions which, unassociated with distinct pulmonary lesion, in- 
dicate very great danger. During the latter part of the eruptive stage, or 
subsequent periods of the disease, inflammation may extend to the larynx 
and trachea, and produce the usual symptoms of laryngitis ; or coryza, 
bronchitis, or lobular or lobar pneumonia, with their several groups of symp- 
toms, may supervene. 

Thirst and loss of appetite are always present in a greater or less degree. 
Vomiting is for the most part a characteristic feature of the invasion, and 
few children fail to suffer from it ; but it does not usually persist. Diar- 
rhoea is not uncommon at the commencement ; after which, the bowels are 
generally, though by no means necessarily, constipated. The tongue varies 
in character — in very mild cases it is only slightly furred, and soon cleans, 
without ever displaying the strawberry-like appearance ; sometimes, it 
very early becomes thickly coated, dry, and even black — sordes appearing 
at the same time on the teeth and lips ; but more frequently, as has been 
pointed out, it is coated at the beginning, and on the fourth and fifth day 
gets clean and unnaturally red, with prominent and swollen papillae; after 
which, it may either gradually acquire the normal characters, or become 
dry and mahogany-like. The soreness of the throat causes difficulty and 
pain in swallowing, and a nasal quality of voice. It involves all the parts 
at the back of the mouth, the fauces, and the upper part of the pharynx, 
but does not usually include the larynx. The tonsils chiefly suffer ; and, as 
has been pointed out, they generally get enlarged, and present on the surface 
opaque patches, which have been secreted by the glandular follicles. In 
mild cases, the soreness may be very slight, and may speedily subside. 
Very often, however — sometimes at the beginning, more frequently in the 
second or third week — the tonsils suppurate, ulcerate, or slough ; or ab- 
scesses and buboes form in their neighborhood ; or a false membrane appears 
upon the surface and extends to other neighboring parts. 

The urine, during the febrile stage of the disease, is scanty and high- 
colored, contains a diminished quantity of chlorides, and not necessarily, 
according to Dr. Gee, any increase of urea. Subsequently it becomes 
more abundant and of a lower specific gravity. Albuminuria is frequently 
present, and its presence is a matter of importance. It appears to have 
no particular connection with the degree of severity of the attack. Indeed, 
many of the severest cases escape it altogether, and many of the mildest 
suffer severely. The time of the first appearance of albumen varies. It 
has been detected on the second or third day of the disease, but commences 
far more commonly in the course of the second or third week, or during 
the period of desquamation. Its amount varies, as also does the period 
during which it persists. The urine is not unfrequently smoky. Under 
the microscope are found hyaline and epithelial casts of the renal tubules, 
and usually also blood-corpuscles, or casts containing altered blood. 

The characters of the rash have already been fully described ; it must be 
added that, during the height of the disease, the skin is generally dry and 
feels pungently hot, and that in ' malignant cases' petechias often make 
their appearance. 

The temperature of the body attains a greater height in scarlet fever 



164 



SPECIFIC FEBRILE DISEASES. 



than in any other disease of the same class ; it frequently reaches 104° or 
105° when the eruption is fully developed, and occasionally rises to 110° 
or even 112°. It differs in its course from that of smallpox, in the fact 
that it rises, instead of falling, when the rash appears ; and from that of 
measles, by subsiding slowly after the rash has reached its acme, instead 
of undergoing a sudden fall. 

The patient complains of soreness of throat, and has some headache and 
giddiness, with general aching of his limbs ; but the pains are not so severe 
as in many other febrile disorders. In the beginning of the disease he is 
generally restless and sleepless, and often a little delirious. When the 
eruption comes out, and during its persistence, he may still be restless and 
excited, or dull and inclined to coma, or he may have more or less de- 
lirium. In grave cases, violent delirium is sometimes one of the earliest 
symptoms. Occasionally, in children, convulsions come on early in the 
disease ; they are rarer, however, than at the commencement of measles or 
smallpox, and are far more serious — indeed are generally followed by a 
fatal result. Coma, delirium, or convulsions not unfrequently usher in 
death. Tremors of the muscles, subsultus, and picking at the bed-clothes 
occur in serious cases. 

No known disease is more unequal in its attacks than scarlet fever. In 
individual cases, it often proves one of the mildest and most trivial of ail- 
ments, often one of the most terrible and rapidly fatal of plagues. In one 
household all the members may have it so slightly that they scarcely ac- 
knowledge to themselves that they have been ill ; and in another not one 
that is attacked survives. And varieties of this kind characterize epi- 
demics. Thus, in many cases, the disease spreads rapidly through a vil- 
lage or town, or over a large extent of country, and its attacks are so mild 
that scarcely a death results ; while in other cases, the epidemic is charac- 
terized by great malignancy and terrible mortality. 

The mildest form has been termed 'latent scarlet fever.' In this the 
cases are so slightly developed that they would probably not be recognized 
as scarlet fever at all, were it not for the fact, either that they occur while 
scarlet fever is prevailing, or that they impart scarlet fever, or that desqua- 
mation, or albuminuria with anasarca, or both, supervene. The patient 
may suffer from slight febrile symptoms only, lasting for a day or two, 
with which may, or may not, be associated evanescent traces of a rash, or 
some degree of roughness of the throat. It is a question, which has already 
been raised, whether the sore throat, which protected attendants on scarla- 
tinal cases so frequently experience, is not the visible sign of latent scarla- 
latina, or rather perhaps of the disease in a modified form. 

The more ordinary forms of scarlet fever are those to which the previous 
detailed description applies. The symptoms of invasion are well-marked, 
the rash is abundantly developed, the throat and tongue are typically 
affected, and the rash disappears between the sixth and the twelfth day of 
the disease, to be followed by desquamation. But cases of medium severity 
may present considerable varieties among themselves. Thus in some, 
while every other characteristic symptom is present, the throat may escape ; 
in some, while the throat suffers severely, the eruption may be imperfectly 
developed. The former cases are often distinguished by the epithet of 
'scarlatina simjjlex the latter by that of 'scarlatina anginosa.' 

The name ' malignan? is commonly given to those cases of scarlet fever 
in which the symptoms are unusually severe, and death tends to come on 
rapidly. It is somewhat loosely applied, however, and embraces cases of 



SCARLET FEVER. 



165 



widely different characters. The most terrible of such cases are probably 
those in which the patient seems to be struck down by the severity of his 
attack, and dies collapsed during the first three days of the disease — some- 
times on the first day, often before the rash has had time to appear or to 
develop, or before the affection of the throat has become a special cause of 
complaint. The symptoms of invasion are severe ; the vomiting probably 
is distressing; the chills or rigors are unusually well-marked; the temper- 
ature attains an extraordinary elevation ; the pulse becomes extremely 
rapid and weak, the respirations quick, shallow, and suspirious ; prostration 
and muscular debility are extreme — there is tremulousness of the muscles 
and jactitation ; the face is dusky and the expression anxious. The patient 
is sometimes sensible, almost to the last ; sometimes there is from the be- 
ginning fierce or muttering delirium, which lapses before death into coma, 
occasionally preceded by an attack of convulsions. Another variety of 
malignant scarlet fever is that in which the throat is gravely implicated. 
The throat-affection may be serious from the first ; but more frequently, 
in a case which presents no very unusual features at the beginning, it under- 
goes aggravation either at the acme of the fever, or during the subsidence 
of the rash, or even on its disappearance. The nature of the affection has 
been already adverted to. There may be abscess of the tonsil, or ulceration 
or gangrene, with oedema of the surrounding tissues ; and supervening 
thereon, the glands in the neck may inflame and suppurate, and sinuses 
form. Under these circumstances the patient is apt to fall rapidly into a 
typhoid condition, and so die ; or he may be carried off by oedema of the 
glottis, perforation of an artery, or pyaemia. Scarlet fever occurring at or 
just subsequently to parturition is excessively fatal, and constitutes one of 
the gravest forms of so-called 'puerperal fever.' It does not appear, how- 
ever, to be especially dangerous during pregnancy, or to lead to abortion. 

The sequelae of scarlet fever are numerous and important. It is diffi- 
cult, however, to make any clear distinction between the complications 
which form an essential part of the disease, and have already been de- 
scribed, and the phenomena which are simply secondary. It is needless 
to repeat what has been said about bronchitis, pneumonia, and ulceration 
of the throat, all of which are apt to complicate the disease in its later 
stages. We will briefly consider the more important of those sequelae 
which have not yet been referred to. First. The conjunctivae not unfre- 
quently inflame in the course of scarlet fever; and occasionally in the 
second or third week of the disease the ophthalmia becomes intense and 
purulent, and sloughing of the corneae may result. Second. Inflammation 
sometimes extends along the Eustachian tube to the tympanic cavity, pro- 
ducing earache or otitis, with disease, may be, of the petrous bone, and, 
possibly, sooner or later, abscess of the brain, pyaemia, or some other fatal 
lesion. Inflammation may extend also to the nose, and produce chronic 
catarrh of its mucous surface. Third. Inflammation of the pericardium 
or of the pleurae (the latter often purulent) is not uncommon. Fourth. 
During the decline of the fever, or even during the period of convalescence, 
rheumatism is very apt to supervene. This differs in no respect from ordi- 
nary rheumatism, involves successive joints and in many cases the peri- 
cardium or the cardiac valves, and adds seriously to the fever and distress 
of the patient. To scarlatinal rheumatism, as to other varieties of rheu- 
matism, chorea or embolism occasionally succeeds. Fifth. The most im- 
portant sequelae of all are, undoubtedly, anasarca and uraemic poisoning. 
We have pointed out that in a large proportion of cases (and for the most 



166 



SPECIFIC FEBRILE DISEASES. 



part in the second or third week) the urine becomes albuminous. Now 
this condition generally passes off without any ill result. But not unfre- 
quently, and more frequently after mild than after severe cases, anasarca 
and urgemia supervene, which may presently be attended with severe head- 
ache, and followed by epileptiform convulsions and death. Under judicious 
treatment the albuminuria and the dropsy may subside; but sometimes 
the urine remains permanently albuminous, and the kidneys undergo slow 
disorganization. It may be observed that anasarca sometimes survives the 
disappearance of the albuminuria; and that it is sometimes developed in 
those who have never had albumen in the urine. Uraemic convulsions 
generally involve a fatal issue. 

Morbid anatomy On post-mortem examination of scarlatinal patients 

most internal organs appear to the naked eye fairly healthy. The liver 
and kidneys may be somewhat softer than natural, and the blood imper- 
fectly coagulated. Yet, well-formed fibrinous clots are not uncommon in 
the right ventricle. In so-called ' malignant' cases, there may be collapse 
and hypostatic congestion of the lungs, and hemorrhage into and at the 
surface of internal organs. The throat generally presents distinct traces 
of inflammation and ulceration. The solitary intestinal glands and Peyer's 
patches are somewhat enlarged. The only other morbid appearances (and 
they are sufficiently important) are such as are connected with the sequeke 
and complications of the disease. These, however, though common in 
scarlet fever, are not peculiar to it, and will be considered with the special 
diseases of the various organs to which they belong, or under other appro- 
priate heads. The microscopic morbid anatomy of scarlet fever has re- 
cently been investigated with minute care by Dr. Klein, 1 who shows that 
even at the earliest stages of the disease there is a marked tendency to 
inflammatory hyperemia and proliferation, not only in the skin, mouth, 
throat, and kidneys, but throughout the alimentary canal, and in the sali- 
vary glands, pancreas, liver, lymphatic glands, and spleen. Generally in 
all these parts there are observed germination of the endothelium of the 
small bloodvessels, hyaline thickening of the intima, germination of the 
nuclei of the muscular coat, and accumulation of lymphoid cells in the 
tissues around; besides which — in the epidermis, swelling and proliferation 
of the cells of the rete mucosum, with serous effusion and migration of leu- 
cocytes between them, and tendency to detachment of the horny layer ; in 
the various epithelia (including those of the renal tubules) changes resem- 
bling those in the skin ; and in the interior of lymphatic glands, especially 
those of the neck, disappearance of the lymphoid cells, and development 
in their stead of many-nucleated giant cells, which ultimately become 
fibrous. A more minute description of the changes which take place in 
the kidneys will be given hereafter. 

Treatment — Whenever scarlet fever breaks out among a number of 
susceptible persons, the sick should be at once separated from the sound. 
The patient should be placed in a suitable room, at the top of the house if 
possible, and if possible should have a floor to himself. All the usual 
measures should be taken as regards nursing, ventilation, disinfection, 
cleanliness, and removal of surplus furniture. He should be kept strictly 
in bed, with only so much covering as is absolutely necessary. His diet 
should consist of milk, beef-tea, eggs, and other such articles. And for 

1 See Report of the Medical Officer of the Privy Council. New Series, No. viii. 
p. 23 et seq. 



SMALLPOX. 



167 



medicine, acetate of ammonia or nitrate or chlorate of potash m solution 
may be serviceable. Some strongly recommend ammonia in large and 
frequent doses ; and some dilute hydrochloric acid, or the perchloride of 
iron. Ice is often useful to allay vomiting. To relieve the soreness of 
the throat, ice, or the inhalation of steam, or warm milk slowly swallowed, 
or astringent or antiseptic gargles may be employed. The patient is gene- 
rally benefited also by tepid sponging, or the tepid douche bath. If the 
bowels are much constipated they should be relieved by laxatives ; if there 
is diarrhoea they should be restrained by opium or other astringents. When 
convalescence is taking place, it is recommended to keep the body well 
greased in order to prevent the dissemination of the flakes of cuticle. The 
practice is a good one, and may be associated with the daily use of warm 
baths. Tonics must now be had recourse to, and the diet should be nutri- 
tious and include a fair proportion of solid food. It is during this period 
that the dangers of rheumatism and of dropsy are greatest. It is important, 
therefore, that the patient should be kept warm, that he should not be 
exposed to draughts, that he should keep his room — either confined to bed 
or encased in flannel — and that the excretory functions should be carefully 
attended to, until the period of desquamation has come to an end. 

In most cases stimulants are not needed ; but in malignant cases, and 
all cases where the muscular debility is great, and there is a tendency to 
collapse, or to the coming on of typhoid symptoms, they are imperatively 
demanded. 

In the severest cases of the disease, however, all treatment is futile ; 
and in the milder cases, the care of the physician must be directed, not so 
much to the cure of the disease, as to the relieving of discomfort, and to 
the obviation by precautionary measures of complications and sequelae. 

If there be nasal catarrh with discharge, it is well to syringe the nostrils 
with warm water, or water containing chlorate of potash, nitrate of silver, 
or some antiseptic. If the throat be ulcerated or gangrenous, solution of 
perchloride of iron or of nitrate of silver, or even the latter in a solid 
form, or hydrochloric or nitric acid, may, according to circumstances, be 
applied. Warm fomentations or poultices should be employed externally ; 
and if there be suppuration in the glands or connective tissue behind and 
below the jaw, a puncture or incision should be made. Otorrhoea, rheu- 
matism, renal dropsy, and uraemic convulsions must be treated as these 
affections are treated when they arise under other circumstances. And so 
with regard to other complications. Only, it must not be forgotten that 
these affections, occurring as complications, bear depletion less and need 
stimulation more, than do the same affections when they are of sponta- 
neous or idiopathic origin. 



VIII. SMALLPOX. {Variola.) 

Definition — A specific fever, spreading by contagion, and especially 
characterized by the appearance on the third day of a papular eruption, 
which gradually becomes pustular, and attains its full development on or 
about the eleventh day of the disease. The eruption shows itself also in 
the mucous membrane of the mouth, fauces, and larynx. 

Causation and history — As with many other of the infectious fevers, 



168 



SPECIFIC FEBRILE DISEASES. 



the history of smallpox cannot be traced further back than the Christian 
era. The first recorded epidemics, indeed, seem to have occurred in the 
sixth century. Since when it has never disappeared from among us, 
has been carried from Europe and Asia over all parts of the world, and, 
down to within a recent period, has formed one of the most formidable 
and fatal of pestilences. The disease was robbed of many of its terrors 
by the practice of inoculation, introduced first into this country, early in 
the eighteenth century, by Lady Mary Wortley Montague, who had wit- 
nessed the efficacy of the procedure in Constantinople, whither it had been 
imported from Persia and China. It was yet more marvelously controlled 
by the application of Jenner's discovery, made at the end of the same 
century, of the protective influence of vaccination ; since the general adop- 
tion of which smallpox has become a comparatively rare and unimportant 
affection. But it still maintains all its old virulence when it attacks those 
who are not protected by vaccination or by a previous attack of the disease, 
and all its old epidemic violence when it is introduced among susceptible 
communities. Smallpox has no special predilection for age or sex ; but 
it is said that dark-skinned races, and especially negroes, suffer more 
severely from it than the denizens of temperate climates. All persons, 
indeed, are liable to take it, unless protected in one or other of the ways 
which have just been adverted to, or (as rarely happens) by some peculiar 
constitutional insusceptibility. Instances, however, are, on the whole, not 
uncommon in which persons have a second and even a third attack — such 
attacks being for the most part mild; and it is a curious circumstance 
that those who, in spite of constant exposure, have enjoyed immunity 
from the disease for many years not unfrequently end by contracting it, 
and have it in a severe form. Whatever the source of smallpox may 
originally have been, there is no doubt whatever that it now comes solely 
by contagion, and that this may be conveyed either through the atmos- 
phere or by fomites, or by direct inoculation with the contents of the vario- 
lous pustules. Few diseases, indeed, are more virulently contagious than 
smallpox; and there is none whose virus remains effective for a longer 
period. 

Symptoms and progress — The period of latency of the inoculated disease 
has been distinctly ascertained to be seven or eight days. On the second 
day a small papule shows itself at the seat of puncture which by the 
fourth day is converted into an umbilicated vesicle. On the seventh day 
the vesicle has formed a pustule ; and about the same time the lymphatic 
glands above have become swollen and tender. And on this day, or the 
eighth, rigors and other symptoms indicative of the invasion of the dis- 
ease occur. About the tenth or eleventh day the pustule is fully developed, 
and at the same time the general variolous rash appears. By the four- 
teenth day the pustule has dried up into a scab. The period of incubation 
is always longer when the disease has been acquired in the usual way. It 
is generally considered then to range between ten and sixteen days.- Ac- 
cording to Mr. Marson, it is almost invariably twelve days. The facts 
connected with inoculation prove that the variolous contagium is present, 
in a concentrated form, in the mature pustules. There can be little doubt, 
therefore, that smallpox is especially infectious about the period of matura- 
tion. But it is probably infectious during the whole period of its duration, 
from the first signs of invasion up to the separation of the last scab. 

The incubative stage of smallpox is, with rare exceptions, unattended 
with symptoms. But occasionally the patient suffers from languor, peevish- 



SMALLPOX. 



169 



ness, and other vague feelings of illness. The invasion is more or less 
sudden, and is indicated by — rise of temperature, chills or rigors, followed 
by or alternating with heat of skin, and generally (in adults) copious per- 
spiration ; severe sickness, with anorexia, thirst, and constipation or (in 
children) diarrhoea; headache, aching of the limbs, and intense pain in 
the lumbar region of the spine; drowsiness, and not unfrequently delirium, 
stupor or coma, and (in children) convulsions. There is sometimes 
maniacal excitement. The most characteristic of the above symptoms are 
the vomiting, constipation, and acute lumbar pain ; it is important, too, to 
note the frequency of perspirations, and of convulsions which for the most 
part are unattended with danger to life. The symptoms of this stage are 
severe in proportion to the severity of the attack which they usher in. 
CcBteris paribus, therefore, the higher the temperature, the more persist- 
ent the vomiting, the acuter the pain in the back, the more pronounced 
the implication of the brain, the more quickly will the disease assume 
grave proportions, and the greater will be its intensity and the prospect 
of a fatal issue. Absence or scantiness of perspiration, and in adults the 
presence of diarrhoea are also indications of a severe attack. 

The above symptoms usually attain their maximum on the third day — 
the day on which the characteristic rash first manifests itself. In a small 
proportion of cases, and these are for the most part fatal cases of great 
malignancy, the eruption appears on the second day ; and occasionally it 
is delayed to the fourth or even later. In modified smallpox, it is not 
unusual to find the true eruption preceded for a day or two by a roseolous 
efflorescence, which has some resemblance to the scarlatinal rash. And 
in cases which threaten to be unusually severe there may be on the second 
or third day of the disease, 1st, a subpapular patchy redness on the face 
and elsewhere, which is almost undistinguishable from the rash of measles, 
but is in fact the commencement of the smallpox eruption in a papular 
form; or 2d, an abundant petechial rash chiefly about the sides of the 
chest and abdomen and on the loins. The rash usually commences, how- 
ever, on the third day, in the form of minute reddish papules, which are 
first visible on the face, head, neck, and -wrists, and in the course of the 
next two days invade successively the upper part of the chest, the arms, 
the rest of the trunk, and the lower extremities. The spots are hard, solid, 
hemispherical or acuminated, and feel like shot imbedded in the skin; 
they gradually enlarge, and in the course of two or three days get vesicular ; 
then, still increasing in area, their contents become opaque and milky, 
and about the sixth day (eighth day of the disease) distinctly purulent. 
With their conversion into pustules, there is a marked extension of inflam- 
mation ; each pock acquires a deep-red areola, and the subjacent tissues 
swell with inflammatory effusion. The pustules still increase in size, and 
the surrounding inflammation still augments, up to about the ninth day 
(eleventh day of the disease). The process of maturation, as it is called, 
is then completed. The above remarks apply more particularly to the 
eruption on the face ; on the lower part of the trunk, and on the extremi- 
ties, its several stages occur somewhat later. The eruption of smallpox 
is always more abundant and close-set on the face and neck than elsewhere ; 
and is generally, even in severe cases, scanty on the lower part of the 
trunk. When sparse the papules, like those of measles, often appear in cres- 
centic groups ; but when they are more thickly clustered this arrangement 
is not observed. If the primary papules are much crowded, the pustules 
which result from them tend to coalesce, and thus to form extensive tracts 



no 



SPECIFIC FEBRILE DISEASES. 



of suppuration, in which the limits between the constituent pustules are 
scarcely or not at all distinguishable. When the pustules remain distinct 
from one another on the face, the attack of smallpox is termed 'discrete' ; 
when they run together in the same situation, it is called 1 confluent.'' 
The pustules of discrete smallpox are always larger than those of the other 
variety, and the surrounding inflammatory areola is more obvious. The 
confluent form, however, is always much the more severe, and attended 
with far greater subcutaneous oedema and ultimate destruction of tissue ; 
the face, and especially the eyelids, are apt to get enormously swollen ; 
and the hands are often so much enlarged and tense that the patient can- 
not close them. The variolous rash is not limited to the skin, but is 
generally developed also, more or less abundantly, on the mucous surface 
of the nose, mouth, fauces, and pharynx, and even on that of the larynx 
and trachea, and sometimes upon the conjunctivae. The fully-developed 
cutaneous pustules are circular in outline, unless altered in form by coales- 
cence or other accidental circumstances, vary from about \ to \ inch in 
diameter, are somewhat flat, and mostly depressed in the centre, or ' um- 
bilicated.' In some cases their contents, even from an early stage, are 
mixed with blood ; and not unfrequently they are associated with petechias 
and vibices. 

In all cases of smallpox, there is, on the first appearance of the rash, 
a sudden diminution of the severe symptoms which characterized the inva- 
sion ; the temperature falls, and becomes in some cases nearly normal, the 
pulse lessens in frequency, the vomiting ceases, the febrile pains and pains 
in the back subside, delirium and other nervous symptoms disappear, appe- 
tite perhaps returns, and the patient seems to be convalescent. At the 
same time, however, the cutaneous eruption is producing some inconven- 
ience : and he begins to complain of soreness in the mouth and tongue, 
with ptyalism, and his throat gets painful, his voice hoarse, and a ringing 
or metallic cough probably comes on — phenomena which are due to the 
involvement in the rash of the mucous surface of the upper parts of the 
respiratory and alimentary tracts. The degree in which the symptoms of 
invasion subside, and the duration of the period of their abeyance, depend 
on the severity of the attack. In very mild cases, the pocks, at the period 
at which they usually suppurate, begin to contract and dry up, and there 
may then be no interruption to the favorable progress of convalescence. In 
cases of medium severity, the period of apparent convalescence continues 
up to the sixth or seventh day of the rash (eighth or ninth of the disease) 
at which time the maturation of the pustules commences. It is then inter- 
rupted by a sudden recurrence of febrile symptoms, which last for some 
three or four days, or until about the completion of maturation. This is 
the period of 'secondary fever,' and is marked by chills or rigors, increase 
of temperature (which may even surpass that of the period of invasion), 
acceleration of pulse, dry furred tongue, and delirium. When the disease 
is of the confluent kind, the remission of symptoms at the commencement 
of the eruptive stage is very slight ; the temperature may, perhaps, sink a 
degree, and there may be some slight general amelioration for four and 
twenty hours, or less; after which, the febrile symptoms and delirium in- 
crease with the progress of the eruption, attaining their maximum severity, 
without any particular change in quality, during the period of maturation. 
It is in such cases that the swelling of the face, hands, and feet is greatest, 
that salivation is most profuse, that other symptoms referable to the mouth 
and throat are most violent, and that delirium is most continuous. There 



SMALLPOX. 



in 



are generally also, in these cases, tremulousness, subsultus, want of control 
over the evacuations, extreme prostration, and not unfrequently diarrhoea. 

After the completion of pustulation, and at the end of the secondary 
fever, which events are generally nearly simultaneous, a period of very 
uncertain duration and of very variable phenomena, during which the 
pustules dry up and disappear, supervenes. During the first three or four 
days, that is, from the eighth or ninth up to the eleventh or twelfth day of 
the eruption, the pustules ooze or dry up, dark-colored, thick, adherent 
scabs form, and the skin begins to exhale a characteristic fetid odor — the 
cutaneous inflammation at the same time rapidly subsiding. The separa- 
tion of the scabs usually takes place during the third week of the disease; 
but the healing of all the sores may not be completed for a week or two 
more, being preceded by the formation and detachment of successive crops 
of scabs. If the case be going on favorably, the febrile symptoms rapidly 
subside, the functions of the various organs are restored, the appetite re- 
turns, and convalescence is established. But it is during this period that 
many of the serious complications and sequelae of smallpox manifest them- 
selves, and delay the patient's recovery, or carry him off. These are most 
frequent after confluent smallpox, but may supervene on the milder forms. 
The following list comprises the chief of them. During the third or fourth 
week, boils are apt to appear on different parts of the surface ; and then, 
though more generally later, subcutaneous and even deep-seated abscesses 
often form rapidly, attain a large size, and are long in healing. Erysipelas, 
more especially of the face and head, is not uncommon ; and gangrene, or 
pyasmia, occasionally supervenes. Pustules sometimes form on the con- 
junctiva? ; and from these or other causes ophthalmia is apt to ensne, which 
may be suppurative and end in ulceration or sloughing, and perforation of 
the cornea. Otitis is sometimes observed. Of internal complications, 
the most serious are suppurative pleurisy, pneumonia, and bronchitis. 
Inflammation or oedema of the larynx may also be fatal about this time ; 
but this event is chiefly to be feared during the period of secondary 
fever. 

The eruption of smallpox generally leads to more or less destruction of 
the cutis vera, and the formation of indelible cicatrices. In some cases 
(especially of the discrete variety) only a few scattered pits may result. 
But in the confluent disease, the destruction, especially on the face, is 
often most extensive, and the patient recovers, pitted, seamed, and scarred 
in all directions. 

The description of smallpox just given is so full that we shall now, in- 
stead of discussing at length the groups of symptoms referable to the vari- 
ous systems and organs, merely supplement it by adding certain details, 
which have either been omitted from it, or only slightly touched upon, or 
are of special importance. 

The temperature, during the stage of invasion, usually rises rapidly to 
104°, or even as high as 106.5°; during the early period of eruption, it 
falls several degrees, but for the most part remains distinctly febrile; at the 
period of maturation, the temperature again rises, in mild cases to 102° or 
103°, in more severe cases to 104°, and when a fatal result threatens to 
107°, or even beyond this. 

The pulse is quickened, especially during the periods of primary and 
secondary fever, but otherwise presents no special peculiarity. The respi- 
rations also are accelerated in relation with the amount of febrile disturb- 
ance, and, under conditions of great prostration and danger, become shal- 



172 



SPECIFIC FEBRILE DISEASES. 



low and suspirious. Vomiting is a characteristic symptom of the period 
of invasion, and anorexia with thirst, of the whole duration of the malady. 
In adults the bowels are generally constipated ; and the occurrence of 
diarrhoea during the development of the rash is an unfavorable symptom. 
In children, however, diarrhoea is a common, and on the whole a favorable 
sign, both in the period of invasion and subsequently. Salivation is 
almost invariable in confluent cases ; comparatively rare and ill-marked in 
mild cases. 

The urine presents the ordinary febrile characters ; and in some cases 
(about one-third of the total number) contains albumen, with casts and 
occasionally blood-corpuscles. Albuminuria appears early in the disease 
and may continue to the end ; but it rarely, if ever, leads to permanent 
renal mischief or to anasarca. According to Mr. Marson, suppression 
never occurs. Inflammation of the ovary or testicle is occasionally observed 
during the eruptive stage. Perspirations are usual in discrete variola from 
the beginning of the disease up to its termination ; but they are generally 
absent in confluent cases, and are not common in children. According to 
the older authors, and also according to Trousseau, the swelling of the 
hands and feet which takes place in confluent smallpox during the period 
of maturation is a favorable sign. 

The invasion-period, in children, is often marked by drowsiness ; and 
coma and convulsions are not unfrequent ; in adults, there is more or less 
giddiness and dulness ; and convulsions occasionally supervene even in 
them ; there is also frequently, and especially in severe cases, maniacal, 
busy, or muttering delirium. In confluent cases, the delirium may con- 
tinue during the early period of efflorescence ; and it generally reappears 
or becomes more severe at the time of the secondary fever. At this time, 
too, the patient is liable to outbreaks of violent mania. Tremulousness of 
muscles, subsultus, and picking at the bed-clothes, occur in the worst cases. 
The pain in the back, which is so characteristic of the onset of the disease, 
appears to be spinal, and is often associated with temporary paraplegia and 
loss of control over the bladder and rectum. 

Many varieties of smallpox have been enumerated. Exceedingly mild 
cases are sometimes observed in which the period of invasion is well- 
marked, but in which no appearance of rash follows, or a few scattered 
pocks only are discovered on the skin or mucous membrane. Other excep- 
tionally mild cases are met with, in which the disease begins with all the 
symptoms that usher in a well-marked attack of the disease ; in which the 
pocks appear numerous yet discrete ; but in which, at the period when 
suppuration should take place, the vesicles dry up. In both of these cases 
there is no secondary fever, and the patient rapidly convalesces. The 
most important forms of natural smallpox, however, are those which are 
known respectively by the names of ' discrete,' ' confluent,' and * malig- 
nant' smallpox. In the discrete form the invasion-phenomena are gene- 
rally well-pronounced ; but the subsidence of febrile symptoms on the first 
appearance of the rash, and their abeyance until the commencement of 
suppuration, are constant ; the secondary fever, too, is generally slight ; 
and the patient for the most part recovers without any complication. 
Nevertheless, in discrete smallpox there is some danger of death on the 
eighth or ninth day of the disease, from the sudden accession of cerebral 
symptoms, especially of coma. In the confluent variety, the symptoms are 
at all stages far more severe than in the discrete form ; especially, there is 
little and very temporary remission of febrile symptoms ; and, moreover, 



SMALLPOX. 



173 



phenomena which are rare or absent in the latter, and have already been 
considered, assume considerable prominence here. It is in this variety, 
too, that complications and sequelae are especially liable to come on. 
Death from confluent smallpox usually occurs from the tenth to the fif- 
teenth day of the disease, and is due for the most part to a combination of 
coma and asthenia. But it may also supervene during the next month or 
two from the effects of sequelae. Malignant s?nallpox is characterized 
especially by the early appearance of petechias and vibices, hemorrhagic 
effusion into the pocks and conjunctivas, discharges of blood from the 
various orifices, and rapid collapse. The symptoms of invasion are usually 
intense, the patient looks from the first as if struck down by a mortal 
disease, and often dies on the fourth or fifth day, or before the eruption 
has had time to become distinct. Occasionally, indeed, the patient dies 
collapsed on the third day, before the appearance of the eruption, but pos- 
sibly presenting chemosis, together with a few r petechial spots about the 
lower part of the abdomen. There may be delirium ; but the patient often 
remains conscious to the last. 

Smallpox occurring after vaccination is generally modified in character, 
and is termed ' modified smallpox,'' or sometimes and inappropriately 
'"varioloid.'' It commences with all the usual symptoms of smallpox, and 
may assume the characters of the discrete, confluent, or even malignant 
forms ; but, about the time when the tissues around the pustules should 
inflame and swell and secondary fever be established, or even before that 
period, the eruption begins to dry up, and the febrile symptoms subside or 
present only very slight and transient exacerbation. Trousseau says that 
delirium is more common in modified than in natural smallpox, but is less 
serious ; and that salivation rarely occurs in the modified confluent affec- 
tion. It need scarcely be added, that the degree of modification varies; 
that the attacks, though generally benign, are sometimes serious ; and 
further, that those occurring, even after successful vaccination, sometimes 
do not deviate appreciably from the natural disease. 

Modified smallpox is for the most part a mild disease, and rarely fatal. 
Natural smallpox, on the other hand, is fatal in a very high degree. The 
statistics of the Smallpox Hospital for twenty years show, that of those 
patients who had previously been vaccinated the mortality was at the rate 
of 6.56 per cent. ; and that of those who had good vaccine cicatrices only 
2.52 per cent. died. It is very different, however, as regards unmodified 
smallpox, which destroyed 37 per cent., or more than one-third of the 
total number attacked. Discrete smallpox was attended with a mortality 
of 4 per cent., semi-confluent with a mortality of 8 per cent., and confluent 
with a mortality of no less than 50 per cent. Statistics from the same 
hospital show that the mortality among patients under five years of age 
was 50 per cent., and among those upwards of thirty still higher. The 
lowest rate of mortality was between five and twenty. According to 
Trousseau, children under one year never recover from smallpox — a state- 
ment, however, which is not absolutely true — those between one and two 
rarely. Mr. Marson states that persons above sixty also almost invariably 
succumb. Pregnant women usually abort and die. They do, however, 
occasionally recover, w 7 hether abortion takes place or not. 

Morbid anatomy The post-mortem examination of smallpox cases 

reveals but little beyond what has been already described. In most cases 
the blood is dark and imperfectly coagulated ; although, in the ventricles 
of the heart fibrinous clots may be discovered. In the malignant form of 



174 



SPECIFIC FEBRILE DISEASES. 



the disease, extravasations of blood may be found beneath all the serous 
and mucous surfaces. The heart is generally flabby, the liver pale and 
soft, and the spleen more or less pulpy. The tongue presents a thick fur, 
which may be detached at the edges and elsewhere in patches. And the 
palate, fauces, nasal fossae, larynx, trachea, and bronchial tubes, and even 
the oesophagus may be found more or less deeply congested, and covered 
with a granular film due to increase and softening of the epithelial layer; 
and may present, in addition, numerous excoriations which from their size 
and distribution are suggestive of their origin in the smallpox rash. Under 
such circumstances, the bronchial tubes are loaded with muco-purulent 
fluid, and the lungs are congested and (Edematous, and possibly pneumonic. 
As regards the skin-eruption, we may here add a few details which were 
out of place in a clinical account of the disease. The papules are due, 
partly to punctiform hyperemia and germination of the cutis, partly to 
swelling, mucous degeneration and vacuolation of the cells of the rete 
mucosum. The central vacuolated cells of the thickened rete presently 
rupture, and unite to form an irregular anfractuous cavity. Into this 
central cavity, and into the surrounding vacuoles, serum exudes from the 
subjacent vessels, together with abundant leucocytes, and often a greater 
or smaller number of red blood-disks. By the continuance of these pro- 
cesses the pock enlarges in area and becomes purulent — its superficial wall 
being formed by the horny layer of the epidermis, its deeper wall by the 
surface of the corium, and its cavity, even to the last, presenting a multi- 
locular or anfractuous character. The umbilical form of the pock appears 
to be connected with its mode of development, and to be due to the fact, 
that while it extends peripherally its centre remains crossed by bands and 
filaments. The suppurative process need not implicate the true skin be- 
low ; but not unfrequently it involves and destroys it to a greater or less 
depth, and is prolonged inwards along the hairs or glands. Under the 
former circumstances the pustule leaves no permanent trace ; under the 
latter a depressed cicatrix results presenting numerous pits upon its surface. 

Treatment — In the mildest forms of smallpox medicinal treatment is 
scarcely called for; in the severest it is useless; and indeed, under any 
circumstances, it has but little influence over the course of the disease. 
The patient should be placed in an airy chamber, which should be well 
ventilated, and kept at a uniform and medium temperature. He may take 
as medicine some cooling drink — lemonade, soda-water, or other saline or 
acidulated solution. If the bowels be confined, they may be acted upon 
by some mild laxative; if there be diarrhoea (especially in adults), they 
must be restrained by opium, or other astringents. The soreness of the 
throat may be relieved by warm bland drinks, or black-currant jelly ; and, 
if there be much discharge from the nose and about the fauces, these parts 
may be washed with some mild detergent or astringent solution. Opium 
is often of value both in relieving the delirium and assuaging the pain of 
the invasion period ; but it is especially useful during the period of second- 
ary fever. If there be great tendency to collapse, ammonia may be service- 
able. Nourishment should be regularly administered, and should consist 
of the materials generally suitable for febrile conditions, namely, milk, 
rice-water, gruel, beef-tea, and such-like. Alcoholic stimulants must be 
given according to circumstances ; but are especially important in the 
malignant form of the disease, and in the later periods of confluent small- 
pox, or whenever there is tendency to collapse. As to local treatment, 
the patient should be kept clean, and frequently sponged with tepid water; 



COW-POX. VACCINATION. 



175 



and, as the eruption reaches its height, and in its decline, the eyes and 
various mucous orifices need especial care. They should be sponged, and 
dried, and anointed with olive oil ; and if there be any tendency to con- 
junctival inflammation and ulceration, weak solutions of nitrate of silver 
or sulphate of zinc should be occasionally dropped into the eyes. Various 
plans have been suggested and employed to prevent pitting ; but it is 
questionable if any is really efficacious. It has been recommended to 
puncture the pustules, to wash away their contents, and then to insert into 
each a fine point of nitrate of silver. If this be done, it should be when 
the pocks first distinctly contain fluid ; but the plan is scarcely applicable to 
the cases in which the prevention of pitting is most needed, namely conflu- 
ent cases. The local application of strong carbolic acid has also been 
recommended. It is probably best, generally, to anoint the surface with 
carbolized oil. During the period of decline of the eruption, and that of 
convalescence, the strength of the patient needs to be supported in every 
way, by good diet, by stimulants, and by quinine or other tonics. The 
various complications of smallpox must be treated according to ordinary 
principles, bearing in mind, however, that their presence as a rule enfeebles 
the patient, and is therefore an indication for sustaining strength. 

But the most important treatment of smallpox is the preventive, by 
means of inoculation with the smallpox virus, or that of cow-pox. The 
former plan has fallen into disuse, and is now penal in this country, yet 
no doubt under certain conditions it might be revived with advantage. 
The inoculated smallpox is a much milder disease than that contracted in 
the usual way; and, according to Dr. Gregory's analysis of the records of 
the Smallpox and Inoculation Hospital of London, from the year 1746 to 
1822, the deaths from it were at the rate of only three in a thousand. 
The mildness of the inoculated disease appears to be promoted by using 
the virus from a mild case, and by repeated selection of inoculated cases 
for the purposes of inoculation. It may be further promoted by inoculat- 
ing those only who are at the age at which smallpox is least dangerous to 
life. The virus should be taken from a pock which has not yet begun to 
suppurate ; and the operation of inoculation should be performed exactly 
like that of vaccination. Our remarks on vaccination will be given in 
the next article. 



IX. COW-POX. (Vaccinia.) VACCINATION. 

Definition. — A contagious disease of cattle, characterized by the local 
development of pustules (almost exactly resembling in their progress and 
results the pocks of variola) and communicable by inoculation. 

Causation and relations with smallpox Cow-pox has been found to 

prevail epidemically at times in every country in Eurjpe. Yet, although 
thus common, it is doubtful if it is communicable from animal to animal 
either by the breath or by the secretions. It is certain, however, that it 
is eminently contagious by inoculation from its specific pocks. Like most 
other affections originating from contagion, cow-pox by one attack protects 
against future attacks ; but it similarly confers immunity against attacks of 
smallpox. It is this fact which gives so great an interest to all questions 
relating to its intimate pathology, and especially to the question of its exact 



176 



SPECIFIC FEBRILE DISEASES. 



relations with smallpox. Its identity with the latter disease was early sur- 
mised ; and many arguments, in addition to the fact that it is protective 
against it, have been adduced in favor of this Aiew. Thus, there is scarcely 
any appreciable difference between the pocks of the two affections, either in 
their anatomical characters or in their progress ; it has been over and over 
again observed that epidemics of smallpox and cow-pox occur in relation 
to one another ; and it is certain that since the introduction of vaccina- 
tion the so-called ' natural' cow-pox has in great measure disappeared. 
But far more important than such facts as these are the experimental proofs 
which have been obtained by Messrs. Ceely and Badcock, and some 
foreign observers. They have inoculated cows with smallpox lymph ; have 
succeeded by this means in producing pustules at the seat of inoculation 
exactly like those of cow-pox ; and with their contents have successfully 
imparted cow-pox to healthy cattle, and to the human being an affection 
exactly like that induced by ordinary vaccination. Further, by lymph 
thus obtained many years ago from bovine smallpox successful human 
vaccination has been perpetuated down to the present time. As confirm- 
atory of this view of the relation between smallpox and cow-pox, it may 
be pointed out, that natural cow-pox occurs only in the teats and udders 
of cows — that is, in exactly the situations in which smallpox would be 
most likely to be given to them by inoculation from man ; and also that 
cow-pox when experimentally inoculated from cow to cow, instead of be- 
ing perpetuated, as it is in man, tends before long to die out. It seems 
clear, therefore, that cow-pox is smallpox, modified and deprived of its 
virulence by transmission through the cow. 1 

Symjitoms and progress in cattle. — Natural cow-pox affects chiefly the 
udders and teats of cows, and is indicated in them by the development of 
a number of pustules which individually run through all the stages char- 
acterizing the smallpox pustules. They begin as papules, in a few days 
become vesicular, and by the seventh, eighth, or ninth day attain their 
full development, measuring then from -| inch to J inch in diameter. 
From that date the contents become purulent, and a congested areola, 
with much subcutaneous induration and thickening, forms. A thick dark 
adherent scab is developed by about the thirteenth or fourteenth day, 
which gets detached in the course of the following week, leaving a de- 
pressed cicatrix. The febrile symptoms which attend the progress of the 
disease are very slight, and for the most part of no importance ; generally, 
moreover, the local affection is quite free from untoward complications. 
When cow-pox is given by inoculation, the papules as a rule first make 
their appearance at the end of three days ; occasionally, however, on the 
second or the fourth day. 

Symptoms and progress in man Cow-pox as it affects the human sub- 
ject differs but little from the same disease in cows. No specific change 
is observable at the point of inoculation until the end of the second day, 
or the third day, when a small congested papule makes its appearance. 
This gradually increases in size, and on the fifth or sixth day has become 
a circular grayish vesicle, with a somewhat depressed centre. By the 

1 Basing our opinions on some experiments of Chauveau, we adopted the oppo- 
site view in the former edition of this work. We have since then reconsidered 
the evidence on both sides ; and are now satisfied that no merely negative evidence 
can invalidate the positive results obtained by Messrs. Ceely and Badcock ; espe- 
cially when we bear in mind that, as is admitted by all, smallpox is not readily 
inoculable on the cow. 



COW-POX. VACCINATION. 



177 



eighth day it has attained its full development — forming then a well-marked 
prominent grayish vesicle with a flat or cupped surface, and containing in 
its interior a colorless transparent viscid fluid. On the eighth or ninth 
day the contents of the vesicle begin to get purulent, a red areola forms, 
and some thickening and induration of the inflamed area take place. 
These phenomena increase during the next two days ; the induration and 
thickening become greater and more extensive, the areola attains a diam- 
eter of from one to three inches, the pock itself undergoes some little ex- 
tension, and its contents get wholly converted into pus. After the tenth 
or eleventh day the pustule begins to dry up, and the areola and other 
signs of inflammation to subside. By the fourteenth or fifteenth day a 
hard dark-colored scab has formed, which contracts and blackens, and 
from the twentieth to the twenty-fifth day falls off, leaving a depressed 
pitted permanent scar. 

The vaccinated patient does not usually present general symptoms or 
complications until about the eighth day, and during the two or three days 
immediately following. There is generally then some febrile disturbance, 
with restlessness, irritability, and slight derangement of the digestive 
organs ; the glands next above the seat of operation usually get enlarged 
and painful ; and sometimes a roseolous rash spreads over the vaccinated 
limb, and thence, may be, to other parts of the body. This rash is some- 
times vesicular or papular. 

When vaccination is performed directly from the cow, the progress of 
the eruption is usually somewhat retarded ; and the local and general 
symptoms are all said to be more severe than when humanized lymph is 
employed. 

In cases of revaccination one of three results may follow : — if the 
patient be fully protected, it produces no effect beyond a little local irrita- 
tion due to the lancet-puncture and the introduction of irritant matter ; 
if all protection have ceased, the operation is followed by the development 
of the typical pock ; if there be simply impairment of protection, the 
results of the operation are modified. In the last case, the local effect 
comes on early, the papule (which may remain a papule or become an acu- 
minated vesicle) attains its full development on the fifth or sixth day, and 
immediately after forms a scab which falls off in the course of a day or 
two; but there is generally a good deal of attendant local and constitutional 
irritation — much more, in fact, than occurs in primary vaccination. 

Other circumstances besides those which have been considered occa- 
sionally modify the results of vaccination — among them, the age of the 
pock from which the lymph has been taken, and the health of the patient 
operated upon. 

It must not be forgotten that cow-pox, whether in the cow or in man, 
is not comprised within its local manifestations ; but that (however mild 
its attack may be) it is a disease involving the whole organism, as is 
proved by the marvellous influence which one attack has in protecting the 
body from subsequent attacks both of cow-pox and of smallpox, by what- 
ever route and in whatever manner they may be introduced. Guided by 
what we know of inoculated smallpox — namely, that, at the seat of inocu- 
lation, a papule appears, which gradually becomes a well-developed pock ; 
that this is simply a local affection, which is followed about the eighth day 
by feverishness and other symptoms of invasion, and in two or three days 
more by the general eruption — it seems obvious to assume, that the pus- 
tules of cow-pox which appear on the udders of cows, and those which 
12 



178 



SPECIFIC FEBRILE DISEASES. 



result from vaccination on the arms of men, are simply, as they appear to 
be, local affections, on which the true generalized disease (in this case 
abortive and altogether trivial in its symptoms) supervenes at about the 
period of maturation — in other words, that the period which elapses be- 
tween inoculation and the full development of the pock corresponds strictly 
to the latent period of other exanthems. 

Protective influence of vaccination against smallpox — A belief in the 
protective influence of cow-pox against variola seems to have been com- 
monly entertained in Gloucestershire during the latter half of the eighteenth 
century. And a similar belief appears to have prevailed about the same 
time in some parts of Germany. It is said, indeed, that a schoolmaster, 
named Plett, in Holstein, vaccinated two children in the year 1771 ; and 
it seems to be established that an English farmer, named Benjamin Jesty, 
performed the same operation on his wife and two sons in the year 1774. 
The value of vaccination was, however, first established on a solid basis 
by the scientific investigations of Edward Jenner, whose attention was 
directed to the subject while he was yet an apprentice, and whose first 
publication in reference to it appeared in the year 1798. "SYe need not 
pursue in detail the further history of vaccination. It is sufficient to say, 
that its practice has been adopted since then throughout the whole civilized 
world ; that the claim which Jenner originally made for it — namely, that 
it is as protective against subsequent attacks of smallpox as an attack of 
smallpox itself is, and neither more nor less so — has been verified by uni- 
versal experience ; that experience and experiment alike have shown that 
its protective influence is in no degree diminished by its continued trans- 
mission from man to man ; and, lastly, that smallpox has died out or 
diminished in severity, in exact proportion as efficient vaccination has 
been generalized. It is certain, indeed, that thorough vaccinal inoculation 
confers in most cases absolute exemption for life ; but that in some cases 
the protective influence diminishes in the course of years, so that if the 
patient contracts smallpox he has it in a modified and mild form ; and that 
where smallpox has been rife, or epidemics have prevailed, the unwonted 
occurrence of the disease has been distinctly traced to neglect of vaccina- 
tion, or to imperfect vaccination, or both. Mr. Marson's tabulated results 
of the experience at the Smallpox Hospital, during twenty years, show at 
a glance the accuracy of the above statements : — 

Number Mortality 

Patients admitted with smallpox. admitted. per cent*. 

1. Having one vaccine cicatrix ..... 2001 7*73 

2. " two " 1446 4-70 

3. " three " " 518 1-95 

4. " four or more " ..... 544 0-55 

5. Stated to have been vaccinated, but having no cicatrix 370 23*57 

It will be recollected that the mortality of primary smallpox is shown, by 
the same authority, to be 37 per cent. 

Dangers of vaccination — The only valid objection to vaccination is 
that it may, and occasionally does, induce or introduce maladies which the 
patient would otherwise have escaped. TTe do not here refer to the im- 
mediate accidental results of vaccination, such as erysipelas and pyeemia, 
which may equally follow on a mere prick or the simplest scratch ; but to 
certain constitutional disorders, such as scrofula and syphilis, which have 
been attributed to it. There is no doubt that syphilis has been thus im- 
parted ; but the recorded cases are marvellously few, and these have been 



COW-POX. VACCINATION, 



119 



the result of gross carelessness or ignorance ; for there is no reason to be- 
lieve that a vaccinated child, who presents no visible indications of syphilis, 
could impart that disease, and but little even to believe that the pure lymph 
of a distinctly syphilitic child is charged with the syphilitic virus. [Mr. 
Jonathan Hutchinson's investigations have, nevertheless, led him to form 
a very different opinion on this point. In the cases that have come under 
his observation, the children, from whom the lymph used in vaccination 
was taken, so far from presenting a puny or sickly aspect, were selected 
for this purpose on account of their apparently excellent health. Nor did 
a minute examination in every instance enable him to detect positive evi- 
dence of syphilis. While admitting that the pure lymph of vaccine vesicle 
is probably never the vehicle by which the disease is communicated, he 
says there is not the least evidence, in three of the four series of cases 
which he has recorded, that the lymph used was visibly contaminated with 
blood. It appears to be sufficient to allow the vesicle to draw or weep. 
With this drainage, he thinks, corpuscular elements of the blood and tis- 
sues become free. In America, where the crusts are almost exclusively 
used, it can rarely be positively ascertained whether or not blood, or some 
product of the tissues, has become mixed with the lymph. It is therefore 
absolutely essential, before using a crust, to know that the child, who has 
furnished it, is entirely free from disease. Inasmuch, however, as vaccina- 
tion, in spite of the exercise of a reasonable degree of care, has occasionally 
been the means by which syphilis has been inoculated, common prudence 
would suggest as frequent a recourse as possible to lymph obtained directly 
from the cow.] As regards scrofula, the only ground for the belief in 
its inoculability by vaccination is the circumstance that lichen, eczema, 
and impetigo — affections which are common in children, especially about 
the period of teething, and by some erroneously regarded as scrofulous — 
occasionally supervene on vaccination, as they do on other forms of local 
irritation. 

Performance of vaccination. — The operation of vaccination should be 
performed at as early a period of life as possible, especially if smallpox has 
been in any degree prevalent. It is now required by law that a child shall 
be vaccinated within three months of birth. It is desirable that it should 
be in good health, and free from skin-disease. In order to obviate the 
tendency which the vaccinal influence has to die out, it is now almost uni- 
versally held that the operation ought to be repeated about the period of 
puberty. And further, it is always important, in the case of persons who 
are, or are liable to be, exposed to smallpox' (especially if they have only 
imperfect vaccinal marks and have not been successfully revaccinated), 
that the operation should be at once repeated. But it should be borne in 
mind that vaccination has no modifying effect on smallpox which has been 
previously contracted, unless it be so timed that the maturation of the vac- 
cine vesicle shall precede the period of the variolous invasion. Thus, since 
the primary vaccine vesicle attains its full development on the ninth or 
tenth day, and the latent period of smallpox is usually twelve days, pri- 
mary vaccination, to have any beneficial effect, should be performed cer- 
tainly not later than the second or third day after exposure to the variolous 
contagion. The vesicle, however, which follows revaccination attains its 
maximum on the seventh or eighth day; so that, if the patient has been 
previously vaccinated, the operation may possibly be beneficially performed 
as late as the fourth or fifth day after exposure. 

The lymph for vaccination should never be taken from persons who are 



180 



SPECIFIC FEBRILE DISEASES. 



diseased, or in whom there is any suspicion of syphilis or other infectious 
disorder ; nor from pocks which are ill-developed or purulent ; nor from 
those which are the product of revaccination. Good vaccine lymph is 
yielded by normal pocks from the fourth or fifth to the eighth day after in- 
oculation. That of a later date should never be employed. As a rule the 
lymph is taken on the eighth clay. The vesicles should be freely punc- 
tured with the point of a lancet, care being taken to avoid hemorrhage ; 
and the fluid which exudes should then at once be employed for vaccina- 
tion, or should be preserved on ivory points which may be dipped into it, 
or between glasses, or preferably in capillary glass tubes. No squeezing 
of the vesicle should be had recourse to ; but if, after all the lymph which 
first flows has been used, the surface be gently wiped, a fresh exudation 
of good lymph usually takes place. Lymph may also be diluted with 
glycerine, in the proportion of from one to two parts of glycerine to one 
of lymph, and thus preserved — a method of special value when lymph is 
scarce. 

Vaccination is generally, and certainly most conveniently performed on 
the upper and outer part of the upper arm. There, four or five distinct 
punctures should be made at \ or | inch distance from one another. Va- 
rious modes of performing the operation are recommended. The simplest 
is to make with a sharp, clean, well-charged lancet, in the stretched skin, 
a valvular puncture directed from above downwards, and sufficiently deep 
to wound the vessels of the cutis. A second method, of which there are 
numerous modifications, is to make groups of parallel or crossed scratches, 
or fine punctures, so as to allow 7 of a little oozing of blood, and then having 
wiped the blood away to anoint the surface with the vaccine lymph. If 
the groups be small they should be five in number ; if large, three will suf- 
fice. If the lymph which is employed be fresh, or have been preserved in 
capillary tubes, it may at once be applied on the point of the lancet ; but 
if it have been preserved in the dry condition, it is essential that it be first 
moistened thoroughly with a small quantity of water. If no result what- 
ever follow the operation, whether it be in a case of primary vaccination 
or in one of revaccination, either the lymph employed is inefficient, or the 
operation has been imperfectly performed, or (which is less probable) the 
patient is insusceptible. Under any circumstances, the operation should 
be repeated until a definite local result of some kind or other is obtained. 



X. CHICKEN-POX. (Varicella.) 

Definition. — A specific contagious disorder, characterized by the appear- 
ance of vesicles in successive crops, which in the course of two or three 
days form scabs. 

Causation — Varicella has been largely confounded with smallpox,* of 
which it has been regarded as a modified variety. This view is still enter- 
tained by Hebra and some other writers. Of the perfect distinction, how- 
ever, between them there can be no doubt ; for the one disease is not pro- 
tective against the other, although each is protective against its own future 
attacks ; the one disease never imparts the other ; and they occur in inde- 
pendent epidemics. Chicken-pox is contagious in a very high degree, and 
spreads both by means of the air and through the medium of fomites. It 



CHICKEN-POX. 



181 



is doubtful whether it has hitherto been imparted by inoculation. It occurs 
epidemically ; but its epidemics seem to be neither so frequent nor so wide- 
spread as those of measles, hooping-cough, and scarlet fever. It attacks 
children mainly, yet adults are by no means exempt. 

Symptoms and progress The period of incubation is somewhat uncer- 
tain. According to different authors, it varies between four or five and 
sixteen or seventeen days. In some cases this stage is exactly of a week's 
duration. But more commonly perhaps it lasts a fortnight. The invasion 
is marked by febrile symptoms, which are occasionally severe, but present 
no distinctive character, and which, generally in a few hours, at all events 
before the completion of twenty-four, are followed by the appearance of 
the rash. This consists, in the first instance, of a number of rosy papules, 
not unlike the spots of typhoid fever, appearing singly, or in groups of two 
or three, on various parts of the body — head, face, trunk, limbs — but most 
commonly, perhaps, first upon the chest. These, in the course of the next 
day or two, or even after a few hours, become distinct vesicles, containing 
a transparent fluid, and usually surrounded by a more or less distinct in- 
flammatory halo. The vesicles, which are at first small and rounded or 
acuminated, increase in size for a day or two, becoming sometimes as large 
as a split pea, occasionally irregular in form, and often umbilicated ; their 
contents at/ the same time get milky. They then rupture or dry up, and 
small dark-colored adherent scabs result. The formation of the scabs is 
completed at the end of four or five days or a week from the first sign of 
illness ; and they may remain adherent for two or three days or even a 
week longer, when they separate, leaving red stains, which are slow to dis- 
appear, and not unfrequently permanent depressed cicatrices. The eruption 
is not limited, however, to the generally scanty crop which first appears. 
But during the first three or four days of the disease fresh crops of papules 
in largely increased numbers, and irregularly distributed, spring up day 
by day; and these go through the same stages as those which were first 
developed. During the progress of the disease, vesicles with inflamed 
areolae usually appear, in small numbers, on the palate, sides of the tongue, 
and mucous surface of the lips and cheeks. 

The general symptoms of varicella are, for the most part, slight and 
unimportant. There is commonly some feverishness, languor, and loss 
of appetite ; and the fever is liable to nocturnal exacerbations during the 
maturation of the vesicles. The temperature often rises to 101°, and may 
reach 104°. The tongue probably remains clean throughout. Occasion- 
ally, the symptoms are much more severe, though never probably so severe 
as to excite serious alarm. Death rarely, if ever, results. 

The malady usually attains its height in a week or ten days, and runs 
its course in ten days or a fortnight. The complications and sequelae are 
unimportant; nevertheless, children often remain weak and out of health 
for some time after an attack. 

Treatment. — The patient should be separated from those who are liable 
to take the disease, and confined to his room, if not to bed. He should 
be prevented, if possible, from scratching his pimples, those at least upon 
the face, in order to diminish the liability to pit. No further special 
treatment is necessary. 



182 



SPECIFIC FEBRILE DISEASES. 



XI. TYPHUS. 

Definition. — A highly contagious fever, lasting from two to three weeks, 
and attended with a characteristic measly eruption coming out from the 
fourth to the seventh day. 

Causation and history. — Typhus fever seems to be a disease especially 
of temperate climates. No European country is free from its occasional 
epidemic prevalence ; but from Ireland it is probably never entirely absent ; 
and, indeed, Great Britain and Ireland may be regarded as its headquarters. 
Epidemics have occurred in the United States and in Canada. There is 
even now some doubt as to whether it has ever been observed in India ; 
but, excepting this doubtful case, it is quite unknown in tropical countries. 
It has been introduced into Australia and New Zealand, but has not spread 
there. Typhus appears, for the most part, in casual outbreaks which as- 
sume an epidemic character, spread widely, and after lasting for months 
or years subside and die out. Almost all recorded epidemics seem to have 
been satisfactorily traced to long-continued overcrowding, in association 
with defective ventilation and personal filth. With these conditions, star- 
vation no doubt is often to a large extent combined. But starvation alone, 
such as results from famine or widespread want (from whatever cause) of 
the necessaries of life, leads to the development rather of relapsing fever 
than of typhus ; while, on the other hand, typhus has not unfrequently 
become epidemic where there has been no starvation, but where the other 
conditions which have been enumerated have prevailed in a marked degree. 
Epidemics of typhus have originated mainly, in the overcrowded parts of 
great cities, during seasons of distress and want and consequent excep- 
tional overcrowding ; in armies, under equivalent conditions ; and in prisons. 
There can be no doubt, indeed, that overcrowding and bad ventilation are 
most effective agents in concentrating the typhus poisoning, and in pro- 
moting the spread of the disease ; and it may be added that anything which 
depresses either body or mind — want of food, fatigue, intoxication, fear, 
anxiety, perhaps even the debility of convalescence — must be regarded as 
a predisposing cause. In the countries in which typhus chiefly occurs, 
seaspn and weather appear to exert no direct influence over either its origin 
or its spread. All ages are liable to its attacks, although it appears from 
statistics that it is most common between fifteen and twenty-five ; and 
males and females suffer from it in nearly equal proportion. One attack 
confers almost complete immunity against subsequent attacks ; yet, occa- 
sionally, two and even three seizures have been observed in the same indi- 
vidual. Excepting those who have thus acquired protection, every one is 
liable to take typhus. It is true that some unprotected persons, even when 
exposed daily to the influence of the disease, fail to contract it ; but many 
cases are on record where such persons, after years of immunity, have been 
attacked with it at last, and have then succumbed to their attack. 

That typhus is a highly contagious disease is established by overwhelm- 
ing evidence. Its poison is carried by the atmosphere, and is absorbed 
and retained in a potent condition for a considerable time by fomites. But 
it presents certain marked peculiarities of behavior external to the system ; 
thus it clings, as it were, around the body of the patient, and seems to be 
rapidly destroyed by diffusion through the atmosphere : so that while its 
operation is intense under appropriate conditions of overcrowding and bad 
ventilation, it is almost nil under opposite circumstances ; and hence the 



TYPHUS. 



183 



disease rarely spreads (excepting to the immediate attendants) in the wards 
of a well-arranged hospital, or among the households of the middle and 
upper classes. The contagium of typhus is probably exhaled with the 
breath and from the general surface. It is doubtful, however, whether the 
other excretions are infective, and whether the disease can be imparted by 
the dead body. Both the breath and the sweat of typhus patients yield a 
characteristic offensive odor, and there is reason to believe that the conta- 
giousness of a case has some direct proportion to its smell. Dr. Murchi- 
son considers that the disease is most contagious from the end of the first 
week up to convalescence. 

Although it is now admitted by all the best observers that typhus when 
once it has made its appearance is eminently contagious ; it is still a moot 
question, whether typhus epidemics owe their origin to new developments 
of the typhus poison, or are due to the presence in a latent form of the 
contagium, which is rendered operative by the concurrence of suitable 
conditions. The former hypothesis is strongly advocated by Dr. Murchi- 
son. His arguments, however, though forcible are not conclusive ; and 
we must confess that the latter view seems to us infinitely more consonant 
than his with the analogies afforded by the exanthemata, and with the 
present state of pathological knowledge. 

Symptoms and progress. — The latent period of typhus appears to be of 
very uncertain duration. Cases are recorded in which the symptoms of 
invasion manifested themselves almost immediately after exposure to the 
concentrated poison. On the other hand, the primary symptoms have in 
some cases failed to appear until after the lapse of twenty-one days, or 
even more. The usual period varies probably between five or six and 
twelve or fourteen days. The invasion is occasionally heralded by an ill- 
defined sense of poorliness lasting for a day or two ; at the end of which 
time, or much more commonly without any such warning, the initial symp- 
toms manifest themselves. These generally consist in a sense of chilliness 
or slight rigors, pain in the forehead and back, and soreness in the thighs 
and other fleshy portions of the limbs ; with which are associated before 
long, or from the commencement, increased heat of skin, occasional slight 
sweats, diffused dusky redness of face and congestion of conjunctivae, 
acceleration of pulse, furring of tongue, anorexia and thirst, scanty and 
high-colored urine, muscular weakness, lassitude, giddiness, and loss of 
sleep, or disturbed sleep with tendency to dream. Occasionally there is 
some nausea or even sickness, and generally the bowels are constipated. 
For the first two or three days, notwithstanding gradual aggravation of the 
symptoms, the patient may not feel sufficiently ill to take to his bed. 
From the third to the seventh day — generally on the fourth or fifth — the 
characteristic measly eruption makes its appearance on the sides of the 
chest and abdomen, and on the backs of the hands, wrists, and elbows, 
and in the course of a couple of days becomes general over the trunk, 
arms, and legs, and sometimes, but much more rarely, shows itself on the 
neck and face. It remains out, well developed but undergoing slight 
changes of color, for two or three days more, then gradually fades, and 
finally disappears by about the fourteenth day, unless it assumes a petechial 
form, when its disappearance is retarded. About the time when the erup- 
tion commences, or a little earlier, the patient has probably taken to his 
bed, and has begun to be apathetic and forgetful, to present a dull and 
listless expression, and to ramble at night. Presently he loses his head- 
ache, becoming, however, increasingly dull, forgetful and stupid; and the 



184 



SPECIFIC FEBRILE DISEASES. 



delirium, which had hitherto been nocturnal and probably limited to the 
moments between waking and sleeping, becomes constant. Occasionally 
the delirium is violent and maniacal, and the patient requires restraint ; 
sometimes it is the busy delirium of delirium tremens ; but much more 
commonly it is of the low muttering kind, known by the name of ' typho- 
mania,' into which, indeed, the other varieties tend soon to merge. In 
this condition the patient can at first be readily recalled to himself, and 
will answer correctly, and do what he is told to do. His aspect becomes 
more oppressed ; the redness of his face and eyes, and his rash, assume a 
more dusky tint ; sordes begin to collect on his teeth, and his tongue be- 
comes dry and brown ; his respirations and pulse increase in frequency, 
and the latter gets small, weak, and sometimes dicrotous or irregular; his 
temperature falls somewhat ; his skin becomes clammy, his limbs tremu- 
lous ; and general debility increases rapidly. By about the tenth day the 
typhoid symptoms of the disease are fully developed ; the patient has be- 
come still feebler ; he lies in bed on his back with his mouth half open 
and his eyes half closed, taking no notice of what is going on around him; 
he is in a semi-comatose condition, muttering at times unintelligibly and 
incoherently, breathing sometimes more rapidly sometimes less rapidly 
than natural, and probably moaning or groaning with each respiratory act; 
his lips and teeth are coated with sordes, his tongue is small, hard, dry, 
and black ; he tends to sink towards the bottom of the bed ; his muscles 
are tremulous, and he has subsultus tendinum, especially in the arms, and 
fioccitatio or a tendency to pick at the bedclothes ; his motions are passed 
unconsciously, but his urine is generally retained, though dribbling away 
perhaps from the over-distended bladder ; his pulse has become extremely 
feeble, dicrotous, irregular ; his temperature probably still shows an in- 
clination to sink ; the rash fades or becomes replaced by petechia? ; and 
perspirations break out. There is a tendency also to the formation of 
bed-sores. 

These symptoms probably continue for several days, the patient mean- 
while becoming more and more prostrate and comatose. And then, gene- 
rally on or about the thirteenth or fourteenth day, either the coma becomes 
profound, the temperature rapidly rises, and the patient sinks ; or he falls 
into a gentle sleep from which, after some hours, he awakes sensible and 
convalescent, with a greatly diminished temperature and pulse, but in a 
condition of extreme debility. If the case continues to go on favorably, 
the tongue quickly cleans, the appetite returns, and restoration to perfect 
health ensues at the end of three or four weeks. 

We will now discuss some of the more important phenomena of typhus 
seriatim. The temperature rises at once, and generally attains its maxi- 
mum, which rarely exceeds 106° in adults and 107° in children, between 
the middle and end of the first week. Exceptionally it does not rise above 
103°. It remains at its maximum for two or three days, and then (usu- 
ally between the seventh and tenth day) falls slightly — continuing to fall 
until the period of crisis, w r hen, according as death or recovery takes place, 
there is either a rapid rise which may exceed by several degrees that 
previously attained, or a sudden fall. The diurnal variations are slight 
and irregular, though on the whole tending to present an evening rise and 
a morning fall. If a high temperature be maintained or an unusual rise 
take place during the second or third week, some inflammatory complica- 
tion is probably present. 

The eruption of typhus embraces two factors, namely, a mere mottling 



TYPHUS. 



185 



of the surface, and distinct dusky-red spots. They are usually present 
together. The mottling, which soon becomes general, precedes the de- 
velopment of the rash, and first appears in those situations in which the 
rash subsequently commences. It is due to the appearance of abundant 
ill-defined dusky patches which are not elevated, vanish on pressure, and 
individually are scarcely perceptible. The rash presents the color and 
very much the aspect of that of measles. The spots, however, are smaller 
and less elevated, and do not assume a crescentic arrangement. They are 
slightly raised, roundish, fading at the margins, and at first disappear on 
pressure. For the first day or two, their color is comparatively bright, 
and due simply to stagnation of blood in the capillary vessels; during the 
subsequent two or three days they assume a dusky hue, the result probably 
in some degree of the transudation of the coloring matter of the blood ; 
and then either they fade away, or hemorrhage takes place into them and 
they become converted into petechia. The typhus eruption is almost in- 
variably present. In the year 1864 it was observed in the London Fever 
Hospital in 97*77 per cent, of the cases admitted. In children it is often 
very slight and of short duration, and may therefore be readily overlooked. 
In adults it is usually well developed ; and generally the severity of the 
disease is in proportion to the abundance of the rash. The copious forma- 
tion of petechia? which often occurs towards the latter part of the second 
week is an unfavorable sign. 

The respirations are generally slightly increased in number during the 
earlier period of the disease. In the typhoid stage they may rise to thirty 
or forty in the minute. From the beginning of the disease there is very 
often a slight cough ; and this may continue throughout the illness ; or it 
may increase and be attended with mucous expectoration which is some- 
times tinged with blood. It is connected with the congestion of the bron- 
chial tubes and lungs which so commonly attends typhus. 

The action of the heart is weak ; and towards* the latter period of the 
disease the first sound often becomes inaudible. The pulse is always feeble 
and generally small ; and its feebleness and smallness increase as the dis- 
ease advances, until at length it becomes undulating, thready, irregular, 
and almost imperceptible. Its rate presents great variety. In adults it 
usually ranges between 100 and 120. During the first few days it rarely 
exceeds 100. Subsequently it rises in frequency; and it may reach 130 
or 140 or more in the minute. But when it exceeds 120 the danger is 
generally very great. Occasionally it falls in the second week to 40 or 
50. In children the pulse is usually much quicker than in adults. 

Sickness is not a common feature of typhus, although it occasionally 
marks its onset. The bowels are generally constipated and the motions 
normal. But occasionally diarrhoea occurs early in the disease ; and it is 
by no means uncommon about the period of the crisis, when also it may 
be dysenteric. The tongue at the beginning may be only abnormally red, 
or even natural; but it is soon covered with a thick whitish fur, which 
gradually gets yellowish, and towards the end of the first week brown. 
Later the tongue shrinks and becomes black ; and equivalent changes take 
place in connection with the lips, palate, and fauces. 

The urine is scanty, high colored, of high specific gravity, and acid, 
during the early period of typhus, and contains an excess of urea and 
sometimes of uric acid and of urates ; which latter may be deposited. 
Later on the urine becomes paler and more abundant, and the urea falls 
considerably below the normal standard. Chlorides are deficient and 



186 



SPECIFIC FEBRILE DISEASES. 



occasionally disappear during the pyrexia! condition. Albumen in small 
quantities, sometimes accompanied by blood-corpuscles and granular casts, 
is frequently present in the urine. It is not certain at what date albumi- 
nuria generally appears, or when it generally ceases; nor is it a symptom 
of importance. It is most common, however, in severe cases, and pro- 
bably usually commences on the third or fourth day. 

Pregnant women rarely miscarry; nor does pregnancy or miscarriage 
add materially to the danger of the patient. The prematurely born foetus, 
if old enough, generally survives. 

The symptoms referrible to the nervous system always form a character- 
istic part of typhus fever. Most of these have already been considered. 
The patient at first has headache, with some dulness and confusion of mind 
(which impress themselves on his manner and on the expression of his 
features), and sleeplessness. In a few days he begins to wander at night 
between waking and sleeping, gradually becoming more stupid and forget- 
ful in the intervals. At the end of the first week or earlier, the delirium 
becomes constant, though still worse at night-time ; and the patient is per- 
haps drowsy in the day. The delirium, as has been pointed out, may vary 
in character, but generally soon lapses into typhomania. Gradually the 
patient becomes more and more unconscious ; and if the case be about to 
end fatally, he probably falls into profound coma, occasionally preceded 
by convulsions. The coma sometimes assumes the character of what is 
termed ' coma-vigil,' in which the patient lies quite unconscious with his 
eyes open and fixed. In the early part of the disease there is generally 
some intolerance of light and singing in the ears.- At the latter part deaf- 
ness often comes on ; and if the patient be comatose the pupils usually con- 
tract to mere points. The muscular pains of the first period, the muscular 
tremors which soon supervene, and the subsultus, floccitatio, and loss of 
control over the rectum and bladder of the later periods, are all more or 
less directly dependent on nervous implication. 

Typhus fever varies in its severity. It is sometimes so mild, of such 
short duration, and so free from any distinctive character that excepting 
under the guidance of attendant circumstances correct diagnosis is im- 
possible. In many cases, again, even where the fever is present in a well- 
marked form, the typhoid stage is never developed; but somewhere between 
the seventh and tenth day, when usually the patient begins to manifest 
the gravest symptoms, amendment takes place — the tongue never becom- 
ing dry and black, the delirium never occurring at other times than be- 
tween sleeping and waking. Next, we have the typical case from which 
our description has been drawn, in which all stages are well developed and 
the commencement of convalescence is delayed to between the thirteenth 
and twenty-first day. Further, we meet with cases in which recovery is 
delayed by the supervention of complications or sequela?. And, lastly, 
cases occur in which the patient dies prostrate and delirious, or comatose, 
within the first week of the attack or even within the first day or two. 

Death is due for the most part to a combination of asthenia and coma. 
It is most common about the end of the second week. Occasionally, and 
more in some epidemics than others, the patient dies from the sixth to the 
eighth day. And many cases are recorded where death has occurred even 
as early as the first or second day. Death at the end of the first week is 
often due in some measure to pulmonary congestion ; and after the four- 
teenth day either to this, or to some other complication or sequela. The 
fatality of typhus is considerable. Of patients treated in hospital the 



TYPHUS. 



187 



mortuary rate is about 15 per cent. But these comprise an exceptionally 
large proportion of the gravest cases ; and there is reason to believe that 
the death-rate among all persons attacked with typhus is no more than 10 
per cent. Among the causes which determine its fatality by far the most 
important is age. Under twenty the mortality is very low. Dr. Murchi- 
son's statistics, taken from the records of the London Fever Hospital, 
show a mortality in cases under five of 6-69 per cent. ; between five and 
ten, of 3-59 per cent. ; between ten and fifteen, of 2-28 per cent. ; and be- 
tween fifteen and twenty, of 4*46 per cent. Between twenty and twenty- 
five the mortality rises to 10-33 ; from which date upwards it increases 
pretty uniformly, lustrum by lustrum, until between fifty and fifty-five it 
amounts to 49*62 per cent., and between seventy-five and eighty to 84-37. 

The sequelae of typhus are not very numerous or characteristic. Among 
the more important may be enumerated, bronchitis and pneumonia, which 
may occur during the progress of the fever or during convalescence; gan- 
grene, in the form of bed-sores, or affecting the toes, fingers, nose, penis, 
or pudenda, or in children mainly in the form of noma; erysipelas; ab- 
scesses in the parotid or submaxillary region, or in the axillae or groins ; 
suppurative inflammation (said to be pyaemic) of joints; anasarca of legs; 
and mental imbecility or mania. These sequelae are all serious ; and two 
of them — noma and suppuration of joints — are almost invariably fatal. 

Morbid anatomy. — The post-mortem examination of typhus patients 
reveals little that is special. There is a tendency in the body to rapid de- 
composition ; the internal organs are for the most part softened and con- 
gested; and the blood is dark, stains the vessels which contain it, and 
coagulates imperfectly. The lungs are usually deeply congested and very 
lacerable in their dependent parts, and sometimes solid from inflammatory 
changes. The spleen is generally softened, and not unfrequently some- 
what enlarged. The large intestines occasionally show traces of dysenteric 
inflammation. 

Treatment It is important that typhus patients should be treated in 

large, airy, well-ventilated chambers, and therefore that they should be 
removed from the overcrowded tenements which as a rule they occupy. 
The attendants upon them should be seasoned and young. In the later 
periods of the disease, the bladder should, if necessary, be periodically 
emptied by means of the catheter, and the patient be kept scrupulously 
clean, so as to prevent the formation of bed-sores. 

The general medicinal treatment of typhus is of little importance. There 
is no specific remedy, and no means which enable us to cut it short. It is 
desirable, however, to relieve the thirst from which the patient suffers, 
and to promote the evacuation by the kidneys of the effete matters which 
speedily overload the blood. For this reason, so-called 'febrifuge' medi- 
cines, which are at the same time mildly diuretic, are doubtless useful. 
Among them we may enumerate, soda-water, and chlorate, nitrate, citrate, 
or other salts of potash well diluted, acetate of ammonia, and the like. It 
is desirable also to keep the bowels fairly open either by occasional laxa- 
tives or by enemata. On the other hand, if there be diarrhoea it should 
be checked by opium or other ordinary forms of astringents. When pul- 
monary congestion complicates the progress of the fever, a little ipecacu- 
anha or antimonial wine with a few drops of laudanum may be added to 
the mixture, or, better still, ammonia. If there be much insomnia or acute 
or busy delirium, opiates in larger doses may be administered by the mouth 
or subcutaneously, or recourse may be had to chloral or bromide of potas- 



188 



SPECIFIC FEBRILE DISEASES 



sium. Rest, too, may be promoted by cutting the hair short or shaving 
it and applying cold lotions or ice to the head. It need scarcely be said 
that opiates should not be given when there is any tendency to coma, or 
to suppression of urine. In the typhoid stage, ammonia is probably the 
most valuable medicine. 

The exhibition of stimulants always becomes an important question. 
There is no doubt that in a large proportion of cases patients do not re- 
quire them ; but there is also no doubt, that many need them, and that 
few if any are injured by them in moderation. In persons of enfeebled 
constitution, in habitual drinkers, and in such as are of advanced age, it is 
for the most part desirable to commence their administration early ; and 
in all cases where the heart shows signs of unusual feebleness, where there 
is extreme prostration, or where typhoid symptoms come on early or are 
severe, stimulants should be at once had recourse to. The amount to be 
given under such circumstances must depend on the condition of the patient, 
and on the effect which they produce. It matters little what form of stimu- 
lant is selected. 

From the beginning the patient loathes food ; but the maintenance of 
his strength is imperative. Hence, those foods which he can be made to 
take should be given to him systematically, in small quantities, and at fre- 
quent intervals. Nothing is better than good milk, of which, by judicious 
management, from two to three or four pints may often be given daily. 
But all patients will not take milk. Alternative articles of diet are rice- 
water, barley-water, gruel, and eggs beaten up with milk, wine, or tea. 
Beef-tea, broth, arrow-root, and jelly are useful adjuncts. Ice may often 
be added beneficially to the patient's drinks. 

During convalescence quinine or other forms of tonics are important ; 
and the diet should be gradually modified to that of health, and should be 
abundant, frequently administered, and wholesome. 



XII. PLAGUE. (Pestilentia.) 

Definition — A contagious fever, closely resembling typhus in its symp- 
toms, but distinguished from it by the absence of any true rash, and by 
the development of buboes and carbuncles. 

Causation and history The early history of the disease to which the 

term 'plague' is now applied is uncertain. It is known, however, to have 
prevailed from an early period of the Christian era in the countries which 
it now mainly affects — namely, Turkey, Asia Minor, Egypt, and Morocco 
— and to have spread thence at various times over the continent of Europe. 
In the seventeenth century numerous epidemic outbreaks occurred in Hol- 
land and in this country, the last being the Great Plague of 1665. Since 
then it has occasionally been imported into the countries bounding the 
Mediterranean basin, and into Russia. In Asia Minor and Egypt it may 
almost be regarded as endemic ; but occasionally, at irregular intervals, 
breaks out into terrible epidemics. Whatever the specific cause of plague 
may be, it is certain that its epidemic occurrence is materially influenced, 
if not determined, by conditions almost identical with those which deter- 
mine outbreaks of typhus — namely, privation, filth, and overcrowding. 
Like typhus it affects mainly the poor, is apt to break out in armies en- 
gaged in warfare, and among the inhabitants of beleaguered cities. 



PLAGUE. 



189 



Plague is eminently contagious, and is communicable by the breath, by 
fomites, and by inoculation. The cause of its spread, therefore, is doubt- 
less a specific contagium. Although an attack of the disease is to some 
degree protective, subsequent attacks have been abundantly met with. 

Symptoms and progress. — The duration of the incubative period is un- 
certain. The symptoms generally commence with chills or rigors, rise of 
temperature, pains in the forehead, back, and limbs, giddiness, anxiety, 
and sickness, on which speedily supervene, great loss of muscular power, 
extreme feebleness of the heart's action — indicated by rapidity, irregularity, 
and smallness of the pulse, and prostration — and marked dulness or stupidity 
of expression, with corresponding hebetude of mind, passing quickly into 
delirium and coma, and sometimes convulsions. The tongue, thickly 
coated from the beginning, soon becomes dry and black. The bowels are 
generally somewhat loose, the urine scanty and occasionally suppressed. 
And hemorrhages from the various mucous surfaces are not unfrequent. 

Within two or three days after the first appearance of symptoms petechiae . 
not unfrequently appear over the surface of the body ; and besides these, 
the more characteristic glandular swellings or buboes, which are chiefly to 
be detected in the neck, axillae, and groins. Subsequently carbuncles 
become developed at various parts of the surface, generally, however, in 
the extremities. The appearance of petechiae is by no means invariable, 
and is regarded as being of bad augury. The buboes enlarge, sometimes 
to a considerable size, reach their height (if the patient survive so long) 
at about the end of the eighth or ninth day, and then either subside, or 
(more rarely) suppurate. Carbuncles are comparatively unfrequent and 
for the most part show themselves towards the decline of the disease ; they 
vary in size and intensity of inflammation, and in numbers from one to 
about a dozen. 

Death from plague sometimes takes place within twenty-four hours after 
seizure. Severe cases not unfrequently prove fatal on the second or third 
day of the disease. Many patients die on the fifth or sixth day. Occa- 
sionally death is delayed until the second or third week ; but is then prob- 
ably due mainly to the effects of complications. 

It is generally acknowledged that it is impossible to distinguish plague 
positively from typhus, either by its early symptoms, or by the first few 
cases that come under treatment — the mode of invasion and the general 
symptoms and progress of the two diseases presenting many points in com- 
mon. Petechiae are frequent in both diseases, and buboes are of occasional 
occurrence in typhus. But plague does not present the" true typhus rash ; 
and the buboes, which are quite exceptional in typhus, are almost constant 
in plague ; and, further, the mortality of plague is much greater than that 
of typhus, and its fatal issue occurs much earlier. 

Morbid anatomy — Patients dead of plague show, as in typhus, a rapid 
tendency to decomposition, fluidity or imperfect coagulation of blood, con- 
gestion, softening and enlargement of organs, and petechial extravasations 
beneath the serous and mucous surfaces. But besides these phenomena, 
there is a general enlargement of the lymphatic glands, which vary individ- 
ually from the size of a goose's egg downwards. This enlargement is not 
limited to the superficial glands, but involves those of the interior of the 
thorax and abdomen, and is often attended with congestion and softening, 
and in some cases with suppuration. 

Treatment The rules and details of treatment which have already been 



190 



SPECIFIC FEBRILE DISEASES. 



given in regard to typhus are applicable to plague. No specific remedies 
are known. Buboes and carbuncles only call for the usual treatment of 
such affections. 



XIII. RELAPSING FEVER. {Fa mine- Fever.) 

Definition A contagious disorder, characterized by a sudden attack of 

high fever, lasting for about a week ; and then apparent convalescence, 
followed after about fourteen days from the primary accession by a second 
attack of fever. A further relapse now. and then occurs about the twenty- 
first day. 

Causation and history The geographical limits of relapsing fever have 

not been fully ascertained. Our knowledge of it has been chiefly derived 
from epidemics originating in Ireland, whence it has spread to England 
and Scotland. It appears also to have broken out independently in Scot- 
land. Epidemics of it have, within the last few years, been observed in 
Russia and Silesia; and there is good reason to believe that it is not un- 
known in America, 1 India, and parts of Africa. There seems to be a very 
close relation between starvation and relapsing fever, which has hence been 
denominated famine-fever. All the more recent and most fully investigated 
epidemics appear to have arisen during the prevalence of extreme destitu- 
tion, and among the classes who have mainly suffered from destitution. 
Further, although the disease is highly contagious and liable to affect all 
who come within its influence, it is mainly carried by tramps and vagrants ; 
and when it spreads among populations not suffering from famine, still 
chiefly affects those sections of them that are least well-fed. Overcrowd- 
ing and filth are almost necessary accompaniments of famine ; but these 
are not thought to have any special influence in the production of relapsing 
fever. At all events, when these conditions exist (as they often do) inde- 
pendently of famine, they are never known to promote the outbreak of 
the special famine-fever. Season and other climatic conditions appear to 
exert no influence over its development or spread ; and its attacks are pro- 
bably in no degree determined by age or sex ; although it is true that 
statistics show a larger proportion of sufferers among males than females. 
The contagion of relapsing fever is carried by the atmosphere, and also 
by fomites. But there is good reason to believe that its influence extends 
but a short distance around the patient, that it is readily lost by dilu- 
tion, and that in order to insure its action a large dose of poison or a 
long exposure to it is essential. There can be no question that when the 
disease spreads its source is a specific contagium, 2 which is evolved by the 
body already diseased and is absorbed by that which is about to suffer. It 
is a debated point, however, whether those who are primarily affected 
breed in their systems the contagion which they afterwards evolve, or 
whether they have derived it from some external source where it has lain 
dormant ; in other words, whether during the progress of starvation the 
specific poison is engendered within the body, or whether the effects of 
starvation are such as to render the frame liable to be affected by a poison, 
which under other circumstances is innocuous. The question is one which 

[' A well-marked epidemic of relapsing fever prevailed in various parts of the 
United States during the winter of 1869-70, and the following spring.] 
2 For further information on this point, see pages 141, 142. 



RELAPSING FEVER. 



191 



scarcely yet admits of a positive solution. Those who look especially to 
the close connection between this fever and famine, and to the long inter- 
vals which elapse between successive outbreaks, naturally lean to the one 
view ; those who give weight to the analogies between it and the exanthe- 
mata lean as naturally to the other. A marked peculiarity of relapsing 
fever, as compared with other diseases of its class, is the fact, that one 
attack does not confer safety from subsequent attacks ; at all events, many 
persons have been known during one and the same epidemic to suffer from 
it two or three times at short intervals. It may be remarked, however, 
that the fact of a patient recovering spontaneously from an infective dis- 
ease is a proof that he enjoys at least a temporary freedom from liability 
to be affected by it. And hence it may be assumed that immunity is 
actually conferred by an attack of relapsing fever, but that the period of 
immunity is mostly of very short duration. 

Symptoms and progress. — The latent period ©f relapsing fevers varies. 
Its extreme limits are probably two and sixteen days. Cases, however, 
are recorded in which the attack seemed to follow almost immediately on 
infection. Dr. Murchison concludes that the period of incubation is, on 
the whole, shorter than that of typhus. 

The onset of the disease is for the most part sudden. The patient is 
seized with a feeling of chilliness or with rigors, attended with severe 
pains in the forehead, trunk, and limbs. This condition is soon followed 
by intense heat and dryness of surface, increased frontal headache, and 
lumbar and other pains, giddiness, frequency of pulse, thirst, and loss of 
appetite. The latter symptoms continue with some slight variation — the 
dryness of skin, however, frequently alternating with perspirations — until 
the third, or more commonly the fifth or seventh day of the disease ; when, 
often preceded by a slight rigor, a copious perspiration almost suddenly 
breaks out, which lasts for a few hours, and is then followed by a remark- 
able reduction in the rate of the pulse and of temperature, and, with the 
exception of some remaining lassitude, almost complete restoration to 
health. 

The following is a more detailed account of the several symptoms which 
attend the febrile attack. The temperature almost from the commence- 
ment is very high, often ranging from 104° to 108-5° F. ; the pulse is 
rapid, generally over 110, and often reaching 130 or 140 in the minute; 
the tongue is thickly coated with a white fur — the tip and edges being 
red — and occasionally towards the termination the centre of the organ gets 
dry and brown ; the teeth are free from sordes; the patient suffers from 
extreme thirst, generally from anorexia and often from vomiting ; in rare 
cases there is slight hasmatemesis ; the bowels are mostly constipated; 
there is often considerable tenderness in the region of the liver and spleen, 
both of which organs become increased in size, and in many cases jaundice 
appears about the second or third day ; the urine varies in quantity, but 
presents an excess of urea, and occasionally contains albumen and even 
blood — towards the later period of attack suppression may take place; the 
pains in the head, trunk, and limbs continue, all being severe, and the 
latter mainly affecting the joints and presenting, therefore, a rheumatic 
character; the patient for the most part retains perfect consciousness, but 
generally suffers greatly from want of sleep and from frightful dreams when 
he does sleep ; delirium, which may be maniacal, sometimes occurs about 
the period of the crisis ; stupor, coma, and even convulsions supervene, 
though rarely, about the same period, and are then probably due to uraemic 



192 



SPECIFIC FEBRILE DISEASES. 



poisoning. The patient seldom presents the congested conjunctivas and 
dull puzzled aspect of typhus fever. The critical perspiration is occasionally 
attended with, or replaced by, an attack of diarrhoea, or of hemorrhage 
from the nose, bowels, or elsewhere. No rash is ever seen, except per- 
haps a few petechias towards the end. 

During the intermission the temperature often sinks below the normal, 
sometimes to 96°, 94°, 92°, or even 90-6°, and it continues low for the 
first two or three days ; the pulse also drops to 40, 50, or 60 in the minute, 
though liable to sudden increase on exertion ; the tongue becomes clean, 
and the appetite often voracious. Occasionally, at the commencement of 
this period, the patient falls into sudden collapse, or passes into a typhoid 
state ; but far more frequently, with the exceptions above adverted to, he 
appears to be restored to perfect health. 

Sometimes the first paroxysm of fever is the only one. But more com- 
monly, at the end of fourteen days (more or less) from the first accession 
of symptoms, the patient suddenly experiences a recurrence of his febrile 
attack. The symptoms which now ensue are as nearly as possible identical 
with those from which he formerly suffered. The temperature, however, 
is often higher, and the duration of the attack for the most part shorter. 
It generally lasts about three days; at the end of which time, convales- 
cence is ushered in with the phenomena which previously ushered in the 
remission. 

Occasionally a third paroxysm takes place on or about the twenty-first 
day; and a fourth and even a fifth recurrence have been observed, though 
very rarely. 

The danger to life from relapsing fever is comparatively very slight. 
Dr. Murchison's statistics show a mortality of only 4-75 per cent. The 
causes of death are mainly asthenia and collapse (the latter of which may 
occur quite suddenly about the period of crisis), coma and other cerebral 
complications, and its sequelae. [There is evidence, however, showing that 
relapsing fever is much more apt to terminate fatally in the negro than in 
the white race. 1 Thus in the winter of 1869-70, when the disease pre- 
vailed epidemically in Philadelphia, the large relative mortality among 
the former excited general attention. This fact contrasts remarkably 
with that of the comparative immunity which this race enjoys as regards 
yellow fever.] 

Convalescence is generally protracted — the patient very slowly regain- 
ing strength — but seldom complicated with serious sequelae. Amongst the 
most common of these are pulmonary affections (more especially pneumo- 
nia), diarrhoea, and dysentery. The most characteristic of them all is 
ophthalmia. It is a remarkable fact that pregnant females affected with 
relapsing fever almost invariably abort, and this no matter what period of 
gestation they may have reached. The foetus, moreover, dies ; the mother, 
as a rule, recovers. 

Morbid anatomy Excepting for the presence of such lesions as are 

due to accidental complications and sequelas, nothing very characteristic 
is noticeable after death. The liver is usually enlarged and congested, 
but otherwise (even if jaundice be present) apparently healthy; and the 
spleen is invariably enlarged to several times its normal bulk, and gener- 
ally softened or diffluent. 

! [According to the report of the Board of Health, of 162 deaths from relapsing 
fever occurring in Philadelphia during the year 1870, 107 were of negroes.] 



DENGUE. 



193 



Treatment. — In the treatment of this disease it is of course necessary, 
in order to prevent its spread, to isolate the sick, and to take the ordinary 
precautions in respect of ventilation and the like. In every case the dis- 
ease will probably run its course, whatever treatment be adopted. It is 
important, nevertheless, to alleviate symptoms and to avert complications. 
To diminish heat, cold sponging or the graduated bath may be serviceable ; 
to check vomiting, ice ; to relieve headache and other pains and to pro- 
mote sleep, perfect quiet, opium or morphia in medium doses, chloral, and 
counter-irritant or sedative applications ; to obviate constipation and por- 
tal congestion, mild laxatives, such as castor-oil, or enemata ; and to en- 
courage diuresis, non-stimulating diuretics, such as bland drinks, and 
medicines containing chlorate, nitrate, or acetate of potash, or acetate of 
ammonia. If coma, attended with suppression of urine, occurs, it may 
be necessary to give purgatives, and to apply cupping glasses over the 
lumbar region. Emetics are recommended by many to be given early in 
the disease ; and bleeding has also been strongly advocated. During the 
febrile attack, the nourishment should be such as is usually proper for 
patients suffering from febrile disorders. Alcoholic stimulants are rarely 
necessary, excepting when there is any tendency to collapse. 



XIV. DENGUE. {Dandy Fever.) 

Definition. — A specific affection, characterized by high fever, inflamma- 
tion of the joints, a peculiar rash, and a tendency to be continued for a 
few weeks by intermittent attacks of short duration. 

Causation and history Nothing seems to have been known of this 

disease until the year 1824, when it broke out suddenly in Rangoon among 
a body of troops. Thence it spread ; and since that time it has occurred 
in occasional epidemics in different parts of India, and also in the tropical 
parts of North America and in the West India Islands, into which it was 
introduced from the East Indies. It does not appear to have extended to 
temperate regions. Dengue is contagious in a very high degree, and 
doubtless, like other such diseases, depends upon a specific virus commu- 
nicated from the sick to the healthy. Its contagiousness, indeed, is almost 
as virulent as that of influenza; and it spares neither male nor female, 
young nor old. 

Symptoms and progress Little or nothing is known with respect to 

the period of incubation of dengue, or to the amount of protection one 
attack affords. The invasion is sometimes preceded by slight premonitory 
symptoms, but much more frequently is quite sudden. Among the early 
phenomena of the disease are — high fever, with sense of chilliness or 
actual rigors, alternating with flushes of heat ; dryness of skin ; severe 
frontal headache with vertigo ; aching in the eyeballs ; pain along the 
spine and in the limbs, but more particularly in the joints ; great rapidity 
and hardness of pulse ; acceleration of respiration ; furred tongue, and 
heat and pain at the epigastrium, with loss of appetite, and very frequently 
sickness ; great muscular prostration, restlessness, and inability to sleep. 
With the advance of the disease, the prostration and the febrile symptoms 
undergo aggravation ; the face and the conjunctivae become congested; the 
pulse rises to 120, 130, or even 140; the tongue gets coated, except at the 
13 



194 



SPECIFIC FEBRTLE DISEASES. 



tip, with a thick, white, moist fur ; and the pains (especially those in the 
joints) are augmented — the arthritic pains, indeed, tending to shift about 
as in ordinary rheumatism, and the affected joints (especially the smaller 
ones) to swell. In the course of a day or two, however, perspirations 
break out, and the severity of the symptoms seems to abate somewhat ; 
but on the third or fourth day of the disease, or a little later, some increase 
of pain takes place, and is attended with an evanescent eruption, which, 
commencing on the hands and feet, quickly spreads over the whole cutane- 
ous surface. This eruption has been likened to that of scarlet fever, 
measles, urticaria, or erythema. From the descriptions it would seem to 
be a kind of erythema papulatum, such as is not unfrequently met with 
in cases of acute rheumatism. It is said to disappear usually on the second 
day, to be attended with more or less itching, and to be followed by des- 
quamation. It is not invariably present. With the subsidence of the 
rash, or about the fifth, sixth, or seventh day of the disease, the febrile 
and other symptoms abate, the patient becomes convalescent, and is then 
soon restored to comparative health. In a short time, however, a relapse 
almost as severe in its symptoms as the primary attack, but lasting only 
for two or three days, occurs ; and to this, after intervals of apparent con- 
valescence, a second and perhaps a third relapse succeed. Usually much 
debility, and not unfrequently pain, stiffness or swelling of the joints, per- 
sist after the final cessation of fever ; and health is generally not com- 
pletely restored under a period of three months. It is important to ob- 
serve that, notwithstanding the high fever, the extreme pain, and the 
general severity of the symptoms under which the patient labors, he rarely 
suffers from delirium, or fails to make a good ultimate recovery. Occa- 
sionally death occurs early in the disease — during the period of deferves- 
cence — from syncope. 

Other phenomena which patients suffering from dengue occasionally 
present are — bleeding at the nose ; swelling of the parotids with saliva- 
tion; swelling of the lymphatic glands, or of the testicles; jaundice, and 
ophthalmia. It may be added that the appetite in some cases continues 
unimpaired, and that pregnant women rarely abort. 

It is obvious that the phenomena of dengue have a considerable resem- 
blance, in some respects, to those of rheumatism, ague, scarlet fever, and 
measles ; with each of which it has been confounded. But it much more 
closely resembles relapsing fever. It resembles this, in its virulence of 
contagion, in its sudden access, in its high temperature with headache and 
arthritic pains, in the rareness of the occurrence of delirium, in its ten- 
dency to be continued by several successive relapses, in its little mortality, 
and even in some of the details of symptoms and sequelae — such as the 
condition of tongue and appetite, the occasional occurrence of jaundice, 
ophthalmia, and inflammation of the salivary and other glands, and even 
in the occasional supervention of death from syncope during the period of 
defervescence. The eruption of dengue (if it be specific) may seem to 
indicate a difference between them, as also may the intensity of the ar- 
thritic inflammation which attends it. Can it be relapsing fever modified 
by climate? 

Of the morbid anatomy of dengue nothing of any importance is known. 

Treatment. — The treatment must be that applicable to other fevers over 
whose course we have no control. Emetics and purgatives have been 
strongly advocated. But, on the whole, it is probably best to administer 
saline or other cooling medicines. The headache and arthritic pains may 



YELLOW FEVER. 



195 



be relieved by local applications, or by the use of opiates ; and complica- 
tions may call for special treatment. During convalescence, quinine or 
other tonics are indicated. 



XV. YELLOW FEVER. 

Definition. — A spreading continued fever, of short duration, character- 
ized especially by epigastric tenderness, vomiting, haematemesis, and 
jaundice. 

Causation and history. — This disease prevails in certain tropical regions, 
mainly in the West India Islands, which seem to be its home, and in the 
neighboring portions of the continents of North and South America. But 
it occasionally invades countries correspondingly situated in the Old World, 
and has even been introduced into the seaport towns of England, France, 
and other parts of Europe. It seems never to spread, however, in these 
latter places, excepting at times of excessive heat. A high temperature 
appears to be an essential condition of its prevalence. It is said, indeed, 
that it never spreads when the thermometer stands at less than 72° Fahr., 
and that even when it is epidemic in a place, it rarely if ever attacks those 
who live more than 2,500 feet above the level of the sea. Outbreaks of 
yellow fever are probably promoted by local conditions of general insalu- 
brity ; and the intensity of the disease is doubtless augmented by them. 
Its contagiousness is denied by many, especially American, writers. It is 
admitted, however, that it attaches itself to foraites, and that it may be 
carried by infected ships into healthy seaport towns, and there produce 
local outbreaks. The evidence, therefore, in favor of its contagiousness, 
is very much of the same nature as that in favor of the contagiousness of 
epidemic cholera and enteric fever. We regard it as contagious, and as 
the product of a specific virus given off from the bodies of the sick. [In 
Philadelphia, where in recent years it has occurred only at long intervals, 
it has always been traceable to the arrival of a vessel from an infected 
port, bringing with it the fomites of the disease. It has invariably affected 
those whose occupations have taken them on board the ship or in its imme- 
diate neighborhood, or those who have lodged the sailors ; the latter un- 
questionably often carrying the fomites of the disease from the ship in their 
clothing. It has, almost without exception, been confined to the part of 
the city in which it first originated, and, so far as is known, no case is on 
record in which a person, having the disease in a previously healthy 
quarter, has become the starting-point of a local epidemic, as is so fre- 
quently observed in measles, smallpox, or, in fact, in any of the truly con- 
tagious diseases. The fact, too, that, until recently, it has rarely appeared 
elsewhere than in seaport towns, is an argument against its communica- 
bility.] There is no good reason to believe that it ever arises spontaneously. 
It spares neither age nor sex ; but one attack confers on the sufferer im- 
munity from other attacks. 

Symptoms and progress The period of latency of yellow fever is said 

to vary between two and fifteen days. Most commonly it ranges from six 
to ten. At the end of this time the patient is generally attacked suddenly 
with acute febrile symptoms, marked by shivering, increased temperature 
(101° to 105°), dryness of skin, congestion of face, redness, suffusion and 



196 



SPECIFIC FEBRILE DISEASES. 



aching of eyes, acceleration of pulse, thirst, anorexia, pains in limbs, and 
intense frontal headache ; to which are soon added acute lumbar and spinal 
pains, slight epigastric tenderness, and vomiting of the mucous and other 
contents of the stomach. The tongue is generally coated with a thick 
creamy fur, except at the tip and edges, which are preternaturally red. 
After these symptoms have lasted, with some variation, for a day or two, 
the febrile condition and the intense frontal and rhachidian pains are apt 
to subside somewhat. But, for the most part, the epigastric tenderness 
becomes more pronounced and the vomiting more constant ; and slight 
yellowness of the conjunctiva? may perhaps be recognized. On the third 
or fourth day, or later, the vomited matters, hitherto colorless or yellow, 
begin to contain blood — sometimes bright, more commonly in the form of 
suspended particles of black pigment — and they soon assume from this 
cause a coffee-ground character, constituting the so-called ' black vomit.' 
At the same time the motions are often dark or black from the presence of 
blood. If the patient do not at once sink, symptoms of a typhoid character 
are apt to supervene; the vomiting may or may not continue; the skin 
probably becomes more decidedly jaundiced and at the same time dusky, 
the teeth covered with sordes, the tongue dry and black, the pulse quick 
and feeble; an eruption of red spots or of petechia? often makes its appear- 
ance on the trunk ; and drowsiness, convulsions, delirium, maniacal ex- 
citement, or coma, supervenes. From the second or third day the urine 
contains albumen, and occasionally a little blood. Later on it gets scanty, 
and is sometimes suppressed. 

Convalescence may (according to the severity of the attack) commence 
from any period of the disease, is marked by the gradual subsidence of 
the graver symptoms, and is generally completed at the end of two or 
three weeks. The jaundice, however, is slow to disappear. The fifth day 
is often regarded as critical. 

The mortality from yellow fever is very high, and death occurs at vari- 
ous periods in its course. In some cases the attack is so sudden and so 
severe that the patient dies in a state of collapse at the end of a few hours. 
More commonly he sinks at the end of two, three, or four days, during the 
period of black vomit — his death then being often due to sudden collapse 
probably determined to some extent by gastro-intestinal hemorrhage. 
Death is not unfrequently thus produced at this time in patients who have 
seemed to be going on quite favorably, and even in those who have hitherto 
suffered so little from the disease that they have not been confined to bed, 
and have been able to follow their employments. At a later date death is 
due, sometimes to cerebral complications, probably referable to ursemic 
poisoning, sometimes to gradually increasing exhaustion. 

The symptoms which collectively are most characteristic of yellow fever 
are, sudden onset with high fever, frontal and lumbar pain, epigastric ten- 
derness, hemorrhagic vomiting, and jaundice. But any of them, and more 
especially the last two, may be absent. Indeed, the symptoms of the dis- 
ease are generally liable to great variation. This depends in great measure 
on the severity of the attack, and on the relative degrees in which the 
several parts of the organism are affected. Mild cases of the disease 
often present no characteristic features whatever, and may be readily con- 
founded with similarly mild attacks of other continued fevers. 

In its sudden onset with frontal headache, lumbar pain and vomiting, 
yellow fever closely resembles variola, from which, however, it soon be- 
comes differentiated. Relapsing fever, again, in its sudden development 



YELLOW FEVER. 



19? 



with fever, headache, pain in the back, and vomiting, followed in a day or 
two by jaundice, presents a marked resemblance to yellow fever ; but it 
differs from it widely in its little fatality, in the absence of black vomit, 
in its sudden cessation at the end of a few days, and in the subsequent 
relapse. Malarial remittent fevers may also be confounded with yellow 
fever, but are distinguishable by many features ; they are endemic and not 
contagious ; one attack favors subsequent attacks ; the febrile paroxysms 
intermit ; there is enlargement of the spleen ; the gastro-intestinal hemor- 
rhages, if they occur, are copious and sudden. Yellow atrophy of the 
liver may be distinguished by its gradual commencement, without marked 
fever, pain, or other characteristic symptoms of yellow fever ; at a later 
period, when the skin becomes yellow, the epigastrium tender, and delirium 
supervenes, the diagnosis may be difficult. Lastly, it may be remarked 
that jaundice is not uncommonly developed in the course of various fevers 
and inflammations, and cannot therefore be regarded as a distinctive mark 
of yellow fever. 

Morbid anatomy The principal morbid conditions observed after death 

from yellow fever are, as might be predicted from the symptoms, to be dis- 
covered in the liver and mucous membrane of the alimentary canal. The 
liver is generally pale, soft, yellowish, or clay-colored (as it is in many 
other acute febrile states attended with jaundice), and somewhat enlarged. 
[These changes in the appearance of the liver were attributed by Pro- 
fessor Clark, of New York, and by Dr. T. Hewson Bache, of Philadelphia, 
who found an excess of oil in the liver, to acute fatty degeneration. More 
recent observers have ascribed them to inflammatory action.] The mucous 
membrane of the stomach is for the most part soft and injected, and the 
cavity of the organ usually contains disintegrated and blackened blood. 
Similar congestion and similar contents may also be met with in the intes- 
tines. Peyer's patches are unaffected. The~spleen is soft, but not enlarged. 
Hemorrhages are not uncommonly met with in the lungs and various other 
parts. Nothing else noteworthy has been detected. 

Treatment. — Many drugs have been recommended and used in the treat- 
ment of this disease. Large doses of calomel and large doses of quinine 
have both been tried. But it seems probable that they have done no good, 
if not harm. The patient should be confined strictly to bed, and not al- 
lowed to make any exertion. He should be kept cool, in an apartment 
well ventilated and devoid of hangings. The secretions of the skin and 
kidneys should be encouraged by diluent drinks, and the bowels kept freely 
open — preferably by enemata. Vomiting should be counteracted by ice, 
and medicinally by lime-water, hydrocyanic acid, spirits of chloroform, 
bismuth, and other stomach-soothing drugs. Wakefulness and delirium 
may be treated with opiates ; headache, precordial uneasiness, and lumbar 
pains relieved by the local application of counter-irritants, cold, or ano- 
dynes. Constant vomiting generally precludes the successful administra- 
tion of food. Under any circumstances, however, this should be bland 
and unirritating, and given frequently and in small quantities. Nothing 
can be better than milk, barley-water, rice-water, or gruel. No doubt the 
great tendency to fall into collapse is suggestive of speedy recourse to alco- 
holic stimulants. Of these brandy and the effervescent wines have been 
most recommended. But they should be given diluted and with caution ; 
for, however beneficial they may prove if absorbed, their local influence 
on an irritable and bleeding stomach can scarcely be other than injurious. 



198 



SPECIFIC FEBRILE DISEASES. 



XVI. CEREBRO-SPINAL FEVER. (Epidemic Cerebro- Spinal 

Meningitis.) 

Definition A specific contagious fever, characterized by inflammation 

of the membranes of the brain and cord, and the symptoms which these 
lesions induce, and frequently attended with petechias, collapse, and early 
death. 

Causation and history. — This disease has only been distinctly recog- 
nized from the time of its epidemic prevalence in various parts of France, 
between the years 1837 and 1848. Since its first appearance in that 
country, it has broken out at various times in Italy, Algeria, Gibraltar, 
Portugal, Holland, Denmark, Sweden, Norway, North Germany, and 
Ireland. In Ireland the disease prevailed between the years 1846 and 
1850, and again with considerable severity between 1865 and 1867. In 
Dantzic a notable epidemic occurred in the years 1864 and 1865. In the 
United States cerebro-spinal fever became prevalent about the same time 
as in France ; and since then there have been frequent outbreaks in different 
parts of that country. It is by no means clear that there has ever been 
any prevalence of the disease in Great Britain. Age and sex, social con- 
dition, and ordinary sanitary circumstances appear to exert little influence 
over the origin and spread of cerebro-spinal fever. Nevertheless, males 
seem on the whole to have suffered in larger proportion than females, and 
soldiers in garrison, in many epidemics, more severely than other sections 
of the population. It appears, also, to be indisputable that the disease 
occurs mainly during the winter months ; and Mr. Netten Radcliffe remarks 
that ' it is noteworthy that the northern and southern limits of distribution 
in both hemispheres but slightly overlap the isothermal lines 5° and 20°.' 
Cerebro-spinal fever is certainly epidemic. Is it also infectious? Of this 
we think there can be little doubt. It is important, however, to note that 
the mode of its epidemic prevalence is not unlike that of cholera or typhoid 
fever, in the facts that it is marked by numerous scattered and for the 
most part small outbreaks, rather than by a general widespread diffusion; 
and that the disease, like these others, although giving clear indication of 
its spread from the sick to the healthy, presents little or nothing of the 
virulence of direct contagion which characterizes most of the exanthemata. 

Symptoms and progress Cerebro-spinal fever is attended in some cases 

by premonitory symptoms, lasting from a few hours to several days, and 
comprising mainly feverishness, malaise, headache, and pains in the back, 
abdomen, and limbs ; but in many cases it comes on quite without warning. 
In either case the first symptoms of the actual outbreak are — severe rigors ; 
intense headache with vertigo; persistent vomiting with more or less severe 
pain in the stomach ; and pains along the spine and in the muscles of the 
extremities, often attended with spasmodic contraction. The patient soon 
becomes restless or irritable, voluble or taciturn, more or less obviously 
delirious or the subject of delusions, and not unfrequently drowsy. His 
head is thrown back, and retained in that position; not so much from spasm 
in the muscles of the neck, as from a voluntary effort to relieve pain in 
that situation ; and his limbs become flexed. He probably cries out at 
times, or screams with the intensity of the pain in his head and back. 
But gradually his mind gets more distinctly affected; he becomes less alive 
to pain and other subjective phenomena; he passes into a condition of busy 
or muttering delirium or into one of acute maniacal excitement, occasion- 



CEREBROSPINAL FEVER. 



199 



ally has convulsions, and then lapses more or less gradually into profound 
coma. In many cases a more or less abundant purpuric eruption makes 
its appearance from the second to the fourth day. Death may occur during 
the first day or two (occasionally after a few hours only) from collapse ; 
or, from this time to the seventh or eighth day, coma due to the cerebro- 
spinal lesion ; or at a later period, even up to the sixth or seventh week, 
from one or other of the complications which are apt to ensue. 

The above is a sketch of the symptomatic phenomena of the disease in 
its ordinary form ; and, as will be observed, they are mainly those of non- 
specific inflammation of the membranes of the cord and brain. They vary 
much, however, in their severity in different cases, and are frequently 
conjoined with other symptoms which are also for the most part dependent 
on the cerebro spinal lesion. We will consider them seriatim^ as they are 
referable to different conditions and different organs. Fever is not usually 
a marked feature of the disease. The temperature appears in many cases 
never to rise above 101° ; but it may reach 105° ; and in cases which are 
rapidly fatal, with symptoms of collapse, it may even sink below the normal. 
The skin varies in its condition, but is seldom pungently hot and dry, or 
profusely perspiring. Besides the petechial eruption which has been de- 
scribed, it occasionally presents patches of erythema or roseola; or groups 
of herpetic vesicles appear upon the lips. Respiration in severe cases is 
more or less embarrassed. It is then generally slow and suspirious, but 
with the increase of depression it becomes hurried and shallow. The pulse 
is much enfeebled, but its frequency is liable to great variation ; sometimes 
it is preternaturally slow, sometimes exceedingly frequent; and rapid 
alterations are apt to occur without any obvious cause. The gastrointes- 
tinal phenomena are of some importance. Violent sickness is a noteworthy 
symptom of the disease during its earlier periods. It comes on without 
any necessary sense of nausea, and independently of the ingestion of food. 
As the disease advances it usually ceases. The severe abdominal pain 
which commonly occurs about the same time is also an important symp- 
tom ; it appears to be strictly neuralgic, and like the vomiting itself refer- 
able to the condition of the central nervous organs. The tongue may be 
clean, or furred, and with the progress of the disease is apt to become dry. 
The bowels are for the most part constipated. The urine in some cases 
contains albumen and blood. The more important symptoms referable to 
the nervous system — namely, neuralgic pains, delirium, and coma — have 
already been enumerated, and we need not recur to them. We may, how- 
ever, point out that numerous additional phenomena are apt to present 
themselves. The patient not only suffers from intense pain in the head, 
not necessarily limited to any one locality, but also from pain in the course 
of the spine and especially in its cervical region, and from neuralgic pains 
in the belly and in the course of the limbs. Cutaneous hyperesthesia is 
sometimes present. We have pointed out that general convulsions are 
occasionally observed ; but more common perhaps than these are local 
spasms either of the tonic or of the clonic kind in various groups of muscles, 
or tremors and subsnltus. Paralysis, either hemiplegic or limited to a 
limb or some other portion of the organism, occasionally supervenes; or 
there may be anaesthesia. Deafness, loss of sight, squinting, inequality of 
pupils, and the like, are also occasionally met with ; and sometimes, in- 
tolerance of light or sound. With the supervention of coma, and often 
before that period, there is loss of control over the bladder and rectum. 
The attitude which the patient assumes is characteristic, at all events, of 



200 



SPECIFIC FEBRILE DISEASES. 



cerebrospinal inflammation ; and his aspect generally affords clear indica- 
tions of the condition of his cerebral and spinal functions. 

If the case be of long duration, various phenomena, due apparently to 
irritation of the nerves or of the centres whence they emerge, are apt to 
ensue — and amongst them, destructive inflammation of the cornea or other 
parts of the eye, or of the internal ear; inflammation, often attended with 
suppuration, of the large joints ; parotid swellings ; and bed-sores. In- 
flammatory affections of the thoracic organs are also not unfrequent. 

The percentage of deaths in cerebro-spinal fever has varied in "different 
epidemics between 20 and 80. 

Morbid anatomy The morbid changes observable after death are defi- 
nite and simple. They consist in congestion of the vessels of the pia mater 
of the brain and cord, and inflammatory exudation into the subarachnoid 
tissue and occasionally into the ventricles. This exudation may be trans- 
parent and watery, but is more frequently opaque, greenish, and distinctly 
purulent. The affection is sometimes general, but more commonly localized 
to some extent ; and not unfrequently it is confined mainly to the base of 
the brain — especially its posterior part — and to the surface of the medulla 
oblongata and upper part of the spinal cord. There is often, also, more 
or less congestion of the substance of the brain. It is said that in some 
cases in which death has occurred speedily from collapse no characteristic 
lesions have been detected. 

Treatment The treatment of cerebro-spinal fever has probably not 

been more successful in its results than that of any other of the specific 
fevers. It must, however, be borne in mind that the mortality of this 
disease is due, less to the direct influence of the specific poison of the dis- 
ease than to the cerebro-spinal inflammation which is one of the immediate 
consequences of its operation. If, therefore, meningeal inflammation be 
amenable to treatment, it is reasonable to believe that that of cerebro-spinal 
fever should be to some extent within our control. Powerful depletory 
measures, however, and -above all the abstraction of blood, are on several 
grounds obviously contraindicated. Counter-irritation, or cold to the head 
and along the spine, and moderate purgation, may possibly be of some bene- 
fit, as also may cooling saline draughts. Opium in large and frequently 
repeated doses, and quinine in large doses, have found much favor with 
American physicians. The food which is administered should be in the 
fluid form ; and its regulated exhibition should be enforced. When symp- 
toms of collapse manifest themselves, stimulants may be had recourse to, 
and the surface should be kept warm. 



XVII. DIPHTHERIA. {Membranous Croup.) 

Definition — A contagious disease, of which the more characteristic phe- 
nomena consist in the formation of whitish membranous pellicles on certain 
mucous surfaces (more especially those of the fauces, nares, larynx, and 
trachea), and on excoriated or wounded areas of the skin; the rapid devel- 
opment of anasmia and extreme debility ; and the supervention, during 
apparent convalescence, of temporary paralysis. 

Causation and history — This disease, although it has been described 
by many authors of ancient and modern times, has been known by its 



DIPHTHERIA. 



201 



present name only since the publication of Bretonneau's treatise in the 
year 1826. He designated it ' diphtherite' (since modified into diphtheria) 
from the Greek word dityOipa, a skin. Diphtheria, like most other infec- 
tious diseases, is met with in the sporadic form, and from time to time 
breaks out into virulent and widespread epidemics. Many of these have 
been recorded. The last of any serious importance prevailed in France 
during the years 1855, 1856, and 1857, and was imported thence into our 
own country, where, from 1859 to 1862, it committed great ravages. It 
was then regarded by a large number of the most experienced physicians 
as a disease almost, if not quite, new to the country. They were well 
acquainted with membranous inflammation of the trachea, or croup — a 
disease, too, which had been known to occur in an epidemic form ; but 
they failed to see, as many indeed still fail to see, that between the char- 
acteristic forms of croup from which the classical description of the dis- 
ease was taken, and diphtheria, there is no essential difference. 1 The 
Scottish and English physicians of the latter part of the last century, and 
the early part of this, had their attention particularly directed to the rapidly 
fatal laryngeal form of the disease, and described it as a local malady. 
Bretonneau, on the other hand, recognized that the laryngeal affection was 
only the occasional complication of a general disease, which was infectious, 
and presented other remarkable features besides the mere formation of a 
membranous lining to the air-passages. Thus, the same disease, described 
from different points of view and from different degrees of acquaintance with 
its pathology, and receiving different names, came to be regarded as two 
distinct diseases. And hence as much confusion has arisen, and as much 
difficulty in recognizing the exact truth, as in the converse case of dis- 
entangling enteric fever and typhus from the discordant descriptions of the 
presumed single disease, continued fever. 

Diphtheria is a disease of all countries and all seasons, and affects both 
children and adults. It is, nevertheless, far more common among young 
children, especially between the ages of three and six, than in persons of 
more mature age, and is both actually and relatively much more fatal to 
them. There is reason to believe, that the sanitary state of houses or 
localities, and the condition of health of those who are exposed to its poison, 
have much influence over its development. It is not very clear, however, 

[l This question is by no means so nearly settled as might be inferred from the 
statement made in the text, for during the recent discussion of this subject in the 
Pathological Society of London, many of the speakers took strong ground in favor 
of the essential difference between pseudo-membranous croup and laryngeal diph- 
theria ; founding their belief upon the fact that cases of croup occasionally occur, 
in which the symptoms indicate merely the existence of a local inflammation and 
not a constitutional disease. There is none of the depression which is the most 
marked characteristic of diphtheria, and which bears no relation to the extent of 
surface involved, but, on the other hand, great distress from interference with 
respiration. Croup of this variety occurs sporadically, and its contagiousness has 
never been proved. Diphtheria prevails epidemically, and is highly contagious. 
The former has sometimes followed exposure to cold. It is scarcely conceivable 
that this would ever be alone sufficient to cause an attack of the latter. In the 
former, emetics and depressing remedies are often of great service ; in the latter, 
they are generally badly borne. The results of tracheotomy are much more favor- 
able in pure croup than in laryngitis. Recovery is also much more rapid in the 
former, and is never retarded by the occurrence of paralysis as in the latter. In 
conclusion, it may he well to state that a membranous inflammation of the larynx 
is sometimes caused by the direct application of irritants, showing that it is not 
necessarily in all cases of constitutional origin.] 



202 



SPECIFIC FEBRILE DISEASES. 



what forms of uncleanliness or what constitutional conditions are most 
influential in this respect ; for we know, that those who appear to be in 
the best of health often take it, while the weakly often escape ; and that 
it attacks the wealthy and the clean as well as the poor, the filthy, and the 
overcrowded. Diphtheria is undoubtedly contagious ; the epidemic of 
1859-62 was distinctly imported into this country from France ; the intro- 
duction of a case into a house, hospital, or other institution containing 
many inmates, is almost certain to be followed by an outbreak of the dis- 
ease amongst them — and indeed it not uncommonly happens that every 
child of a large household is thus swept away ; the nurse contracts it from 
her charge, the doctor from his patient, the mother from her suckling. 
The contagion is doubtless carried by the atmosphere. But it may also 
lie dormant in fomites, and thus present prolonged vitality ; for it is 
certain that many cases have been met with in which children, brought 
into rooms which had been well purified subsequently to the occurrence of 
diphtheria in them several weeks or months previously, have taken the 
disease. There is no doubt that it can be imparted by inoculation. Many 
cases are recorded (such, for example, as that of Professor Valleix, in 
whom a fatal attack supervened on the reception into his mouth of a small 
quantity of saliva coughed out by a diphtheritic child) where accidental 
inoculation seems to have been efficacious; yet, on the other hand, both 
Trousseau and Peter have inoculated themselves without effect. Experi- 
ments upon the lower animals have latterly been largely performed, but 
with results which are not entirely conclusive. The most important are 
those of Letzerich, Oertel, and Trendelenburg, in which they claim to 
have given diphtheria to rabbits by the introduction of diphtheritic matter 
into the trachea. 

It may be presumed that the patient is most apt to impart the disease 
while the membranous exudations are present ; but it is by no means 
certain at what period he ceases to be infectious. Convalescent children — 
children, that is, who appear to be perfectly well and have been apparently 
well for two or three weeks — seem occasionally to give the disease to 
others. 

Symptoms and progress The period of incubation is not accurately 

known. Some patients appear to have had the first symptoms of diph- 
theria a few r hours only after exposure to its virus. In others the disease 
has not manifested itself for eight days. The incubative period probably 
varies between these extremes. Whether it is ever longer must be re- 
garded as doubtful. The symptoms of invasion vary in some degree in 
their intensity with the virulence of the attack they usher in. For the 
most part they consist in elevation of temperature and other evidences of 
febrile disturbance, together with slight uneasiness or soreness of the throat. 
But these are often so slight, that the patient makes little or no complaint, 
and pursues his ordinary avocations, until perhaps (especially if he be a 
child) attention is attracted to him by the presence of pallor, languor, and 
dulness or tendency to mope. Sometimes the febrile symptoms are much 
more marked, and there may be distinct chills or rigors; but there is rarely 
even then any great complaint as to the condition of the throat. If, on 
the first evidence of illness-, the interior of the throat be examined, there 
will probably be observed some degree of redness and tumefaction of the 
tonsils, pillars of the fauces, soft palate or pharynx, or of all of these parts. 
And very soon afterwards, whitish, grayish or buff-colored, opaque, well- 
defined, patches will be visible on some parts of the congested surface — 



DIPHTHERIA. 



203 



often on one or both tonsils. These vary in thickness, are more or less 
coherent, admitting of removal in shreds or as a whole, and are mode- 
rately adherent to the subjacent surface, which is left excoriated but not 
excavated by their removal. They tend rapidly to spread, and hence if 
multiple to coalesce, and at the same time to become thicker and more 
adherent; and may thus in the course of a few days, form a nearly con- 
tinuous covering to the whole surface above indicated, including that of 
the uvula. And, indeed, the throat may be found already in this condi- 
tion, at the time when attention is first seriously attracted by the general 
aspect of illness which the patient presents. By this time, the tonsils are 
often considerably enlarged, and the uvula swollen and oedematous ; there 
is almost invariably manifest swelling and tenderness of the lymphatic 
glands about the angles of the jaw ; there is generally, also, more or less 
mucous exudation and accumulation about the fauces ; but rarely, either 
the total loss of appetite, or the great agony in mastication and swallowing 
which attend ordinary tonsillitis. 

The course which the disease may take from this point is very various. 
In some cases, the febrile symptoms soon subside, the morbid process 
ceases to spread, and the patient rapidly convalesces. In some cases, the 
membranous formation extends along the oesophagus, reaching it may be 
to the stomach. In some, it spreads to the larynx and trachea, and occa- 
sionally thence to the bronchial tubes. In some, it invades the posterior 
nares, extending possibly throughout the whole of the nasal cavity and 
even along the lachrymal ducts to the conjunctivas. In some, the inflam- 
mation spreads in depth, and the glands and other soft tissues in the sub- 
maxillary and adjacent regions get swollen and infiltrated with inflammatory 
matter. And in some, diphtheritic pellicles make their appearance on 
other mucous surfaces, or on excoriated or ulcerated parts of the skin. 
We will discuss these various cases categorically. 

1. The first of the above varieties of diphtheria is often a very mild 
disorder. The patient — with little or no fever at any time, with scarcely 
any complaint of soreness of throat, with no material thirst or loss of appe- 
tite, and with perhaps a small white patch on one or other or both tonsils, 
which may even have disappeared before the throat comes to be examined, 
or which may be detached at the end of three or four days, or a little 
later — becomes convalescent in the course of a week or ten days, and then, 
except probably for some unusually persistent anaemia and debility, and 
perhaps for some enduring enlargement of the cervical glands, is soon 
restored to health. When, however, the membranous exudation covers 
an extensive surface — especially if, at the same time, the tonsils and uvula 
are much swollen — the symptoms are far more serious, and the duration 
of the malady is prolonged ; but even then, if no complications arise, the 
patient is generally convalescent at the end of ten days or a fortnight. 
There is commonly under these circumstances great and increasing debility, 
and anaemia ; and not unfrequently the patient, who has been perfectly 
sensible all along, dies from asthenia or in a fainting fit following some 
slight exertion. Occasionally, and more commonly in adults than children, 
the breath acquires a fetid and distinctly gangrenous odor — the false mem- 
brane at the same time assuming a dirty gray or blackish hue, and a more 
or less pultaceous consistence. These phenomena are seldom due to 
actual gangrene, but are generally the result of mere decomposition of the 
diphtherial exudation. 

This is perhaps the best place to point out, that diphtheritic patches not 



204 



SPECIFIC FEBRILE DISEASES. 



unfrequently make their appearance on the inner surface of the cheeks and 
on the gums, especially in the neighborhood of the pillars of the fauces, 
and sometimes at the margins of the lips ; and, further, that Bretonneau 
has described an affection of the gums (frequently associated with distinct 
faucial diphtheria and evidently of the same nature) in which an abundance 
of rust-colored tartar accumulates about the necks of the teeth, in associa- 
tion with marginal pellicular formations on the gums, and a tendency to 
the development of similar patches on those parts of the inner surfaces of 
the lips and cheeks with which the diseased gums are in contact. There 
is excessive fetor of breath and disposition to gingival hemorrhage. 

2. Extension of the diphtheritic inflammation along the oesophagus is 
not very common, nor is it attended with any marked special symptoms. 
Both difficulty and pain in swallowing, and complete and unconquerable 
anorexia, are not unfrequent accompaniments of severe cases of simple 
diphtheria, and hence would not be characteristic of this complication, 
although they would probably attend it. 

3. Diphtheria of the air-passages constitutes one of the most frequent, 
and at the same time one of the most fatal, of the varieties of the disease. 
In some cases, no doubt, the larynx or trachea is the primary seat of in- 
flammation and membranous exudation, the fauces remaining healthy. 
Under these circumstances, croupy symptoms manifest themselves simul- 
taneously with the first onset of febrile disturbance, and we have in fact a 
case of typical croup. In a much larger number of cases, however, the 
laryngeal mischief supervenes on ordinary pharyngeal diphtheria, the 
membranous inflammation extending from the one part to the other by 
continuity. But since in this case the preceding affection of the pharynx 
is often exceedingly slight, not to say trivial, and has very likely given 
little or no positive indication of its presence, the laryngeal sequence is 
very apt to be assumed to be the primary disorder ; and, again, the case 
falls in with the classical descriptions of croup. In many cases, however, 
the pharyngeal affection is severe ; and has been recognized, before the 
symptoms of croup appear. Here the sequence, of events is obvious. 

Thus, diphtheritic affections of the larynx and other air-passages either 
may be secondary to pharyngeal diphtheria, or may commence in the 
larynx, trachea, or possibly even bronchial tubes, and then either remain 
limited to these parts or spread upwards to the pharynx. Under any cir- 
cumstances the symptoms resulting from the laryngeal or tracheal affection 
are of the same kind, and of extreme gravity. The child (for although 
membranous croup occurs in adults, it is mainly children who suffer) is 
first attacked with a frequent, short, dry, perhaps metallic, cough, and 
slight hoarseness of voice — symptoms in this affection of the w r orst omen, 
even if in other respects he appears, as he often does, to be fairly well. 
But soon, some difficulty of breathing supervenes, commencing usually in 
the night. The symptoms now rapidly increase in severity ; breathing 
(inspiration more than expiration) becomes noisy, sibilant, stridulous, or 
metallic, especially after an attack of coughing ; the voice grows hoarser 
and weaker, or fails ; the cough gets less frequent but more severe — 
paroxysmal, suffocative, harsh, unmusical, and wheezy, or far less com- 
monly hard and metallic ; and during the paroxysms the child tosses itself 
about, sits up, clutches whatever is near it, throws its head back, opens its 
mouth, dilates its nostrils, and struggles for breath : the general surface 
and especially the face become livid, the eyes staring, and the expression 
one of intense anxiety. Even now, in the intervals between the paroxysms 



DIPHTHERIA. 



205 



of cough, the child often assumes a fallacious appearance of ease and com- 
fort ; the breathing may be little quickened, and, unless under excitement, 
attended with little noise ; and the best hopes of recovery may arise. But 
the paroxysms return and increase in frequency and severity ; until at 
length, overcome by his exertions and progressive suffocation, the patient 
passes into a condition of combined coma, asphyxia, and prostration, in 
which he dies. Death takes place sometimes in a few hours, rarely later 
than the fourth or fifth day after the commencement of symptoms. In 
adults the course of the disease is usually not so acute. It should be added 
that during the progress of the attack, the respirations increase in fre- 
quency; the pulse becomes small, weak, and rapid; the surface, especially 
that of the extremities, gets cold; and perspirations break out; and further 
consciousness remains for the most part unimpaired almost to the close. 
The symptoms above detailed are clearly referable to the gradual growth 
and extension of false membrane in the larynx and trachea, and are occa- 
sionally relieved by their expulsion in the act of coughing. The paroxys- 
mal cough is probably chiefly dependent on the occasional blocking up by 
mucus of the narrowed rima glottidis or trachea, and on spasm. The 
spread of the false membrane throughout the bronchial tubes, and the su- 
pervention of lobular pneumonia, are indicated mainly by rapid advance 
of lividity and asthenia, increasing imperfection of the respiratory acts, 
with falling in of the lower ribs and intercostal spaces during inspiration, 
inefficiency and feebleness of cough, and suppression of the auscultatory 
phenomena of the lungs. Emphysema of the connective tissue of the neck, 
head, and thoracic parietes, is occasionally developed. 

4. Extension of the diphtheritic process to the nose, or the deeper tissues 
of the neck, constitutes an essential feature of the so-called 'malignant' 
form of diphtheria, and indicates severe concurrent constitutional poison- 
ing, and an almost certainly fatal issue. Malignant diphtheria often comes 
on with no more severe symptoms than those which attend the commoner 
forms of the disease ; and even when local signs indicate the course the 
malady is taking, and the observant physician foresees and dreads the im- 
pending change, there is frequently nothing in the patient's condition to 
alarm himself or his friends. The spread of the disease to the nose is in- 
dicated by catarrhal symptoms, by redness and soreness of the nostrils and 
by the discharge of mucus, frequently attended early with some degree of 
epistaxis, and, ere long, with a copious flux of bloody ichor. At the same 
time the lachrymal ducts become involved, the escape of the lachrymal 
secretion by the puncta is arrested, the eyes water, and occasionally false 
membranes form on the conjunctiva?. On inspection of the anterior or pos- 
terior nares the existence of the false membrane in the nose will probably 
be clearly recognized. The extension of the inflammation in depth is 
shown, partly no doubt by progressive enlargement of the tonsils and 
thickening of the soft palate and uvula, but more especially by rapid in- 
crease in size of the lymphatic glands about the angles of the jaw, and by 
infiltration with inflammatory products of the connective and other tissues 
which intervene between them. By these processes very considerable 
general tumefaction is produced; extravasations of blood and suppurating 
cavities appear here and there in the substance of the mass ulceration or 
gangrene occasionally takes place at the mucous surface; and the cutaneous 
aspect, either uniformly or in patches, becomes brawny and congested or 
livid. In malignant cases, anaemia and prostration come on with great 
rapidity; the pulse early becomes quick, irregular, extremely small and 



206 



SPECIFIC FEBRILE DISEASES. 



feeble, and the surface cold ; hemorrhage frequently takes place from 
the mucous orifices, and petechia? and vibices appear beneath the skin ; 
the patient is restless and occasionally delirious ; and death results from 
asthenia. 

5. Although, in the vast majority of instances, diphtheria commences 
either in the pharynx or in the mucous cavities which communicate di- 
rectly with it, cases are occasionally met with (especially during epidemic 
outbreaks and amongst the members of infected households) in which the 
diphtheritic inflammation and pellicular formation first make their appear- 
ance in some other region — occasionally in the vulva or vagina, on the 
glans penis and foreskin, at the anus, in the external auditory meatus, or 
on excoriated or raw cutaneous surfaces. The local changes here are 
identical with those occurring in the more usual seats of this disease ; the 
redness of the affected part is more or less vivid and intense, especially in 
a narrow zone circumscribing the adherent pellicle ; the pellicle is white, 
buff, gray, or black, not unfrequently looking like an eschar, and adherent 
to the surface ; and (when the skin is the part involved) its extension is 
attended with the formation of vesicles at the margins, which run together, 
and lead to the development of spreading excoriations which presently get 
clothed with the enlarging pellicle. Just as in many cases of primary 
pharyngeal diphtheria false membranes appear after a while on various 
parts of the surface of the body; so, in the cases now under consideration, 
it is not uncommon to find the pharyngeal mucous membrane ultimately 
involved. 

There are two or three important points in relation to diphtheria which 
have been either quite passed over, or only touched upon, in the foregoing 
account, but must not be forgotten. The temperature of diphtheria is 
never a characteristic feature, and is rarely high. In some, and even 
severe cases, it scarcely at any time exceeds the normal ; generally, how- 
ever, there is distinct elevation during the first day or two, and occasion- 
ally — but more particularly in those cases in which the larynx and trachea 
are implicated — the temperature rises in the course of the disease to 106° 
or 107° and upwards. The urine in a large proportion of cases (one-half 
or two-thirds, according to different observers) becomes albuminous at an 
early date, the amount of albumen being sometimes very great. Occasion- 
ally, and more especially in malignant cases, there is haematnria. Under 
the microscope will be found, in the former case hyaline and granular 
casts, in the latter blood more or less modified in character. These con- 
ditions of the urine are rarely of long duration, and scarcely ever usher in 
dropsy, uraemia, or permanent lesion of the kidneys. Urea is excreted in 
excessive quantities during the progress of the disease, and diminishes 
during convalescence. Inflammation now and then extends from the 
throat to the ear, and may produce suppuration and other serious lesions 
in that organ ; and occasionally it spreads from the conjunctiva to the cor- 
nea, causing opacity, ulceration, and perforation. Delirium is of unusual 
occurrence, and generally forebodes a fatal issue. 

The duration of diphtheria varies widely. When the disease ends in 
convalescence it rarely exceeds a fortnight ; and it may be as little as a 
week. Death occurs at very different periods, which, however, are very 
much determined by the nature of the lesions inducing it. It may take 
place within the first twenty-four hours, or as late as the end of the second 
week, or at any intermediate period. The causes of death have been suffi- 
ciently considered. The mortuary rate of diphtheria is high; but it is im- 



DIPHTHERIA. 



207 



possible to make any exact statement on this point ; for while in some- 
epidemics, undoubtedly, many mild cases occur of which a large propor- 
tion are never suspected to be diphtheria, in other epidemics the fatality 
of the disease is frightful. The most fatal forms of diphtheria are those in 
which the air-passages are affected, especially in children, and those which 
have been spoken of as malignant. 

Diphtheria does not always cease with apparent convalescence. In 
many cases, morbid phenomena of a totally different kind to any which 
have preceded sooner or later supervene. These are affections, for the 
most part paralytic, of the sensory and motor nerves. They sometimes 
commence with the separation of the false membrane, but more commonly 
come on from a week to a month after convalescence seems to have been 
established. Usually the first, and not unfrequently the only part affected 
is the soft palate. The patient, who had probably regained his voice and 
power of deglutition, begins to speak with a nasal tone ; when he attempts 
to swallow, a portion of his food is apt to pass into the posterior nares ; 
and on examining the throat, the soft palate is found to be more or less 
pendulous and motionless — motionless even when mechanically irritated ; 
its sensibility also is impaired or annulled. It is worth while pointing out, 
as showing that the palatal paralysis is not the result of local inflammatory 
changes, that it occurs in cases in which pharyngeal or faucial inflamma- 
tion has been very slight, and even in cases where there has been none. 
The paralysis, however, does not necessarily stop here ; but soon, it may 
be, the patient begins to complain of numbness, tingling, and loss of power, 
in one or both lower extremities ; then probably the upper extremities are 
attacked in the same manner ; presently perhaps, the sensibility of the 
trunk diminishes and its muscles lose their force, the intercostal muscles 
and the diaphragm fail, and even the rectum and bladder share in the 
general paresis. Further, the paralytic condition, commencing in the 
fauces, may spread so as to involve, on the one hand, the muscles of mas- 
tication, articulation, and expression, and on the other the larynx, lungs, 
and heart, and generally the organs to which the vagi are distributed. In 
addition, complete failure of sexual power and appetite often comes on, 
and more or less impairment of the organs of sense. There may be loss of 
smell or taste, or deafness. But it is chiefly the eyes that suffer: — squint- 
ing and double vision, and loss of adjusting power by reason of paralysis 
of the ciliary muscle are not uncommon; and temporary amaurosis some- 
times takes place. It is important to note that, although all the forms ot 
paralysis above specified may occur, they rarely all occur in the same in- 
dividual, and never all at the same time, or in the same order. The 
paralysis, in fact, is progressive, and often tends to get well in one part 
while it is extending elsewhere ; and, like hysterical paralysis, it frequently 
shifts from one region to another. In place of paralysis, we sometimes 
meet with hyperesthesia and neuralgic pains. Notwithstanding the alarm 
which the presence of paralysis necessarily creates, the paralytic condition 
is rarely fatal, and generally ends in perfect recovery in the course of two, 
three, or at the outside four, months. 

But it is not altogether devoid of danger. When death occurs from it 
it is mostly in those cases in which the paralysis is rapidly developed and 
extensive, and in which the nerves arising from the medulla oblongata 
and floor of the fourth ventricle are especially implicated. The patient 
may die from inability to swallow food, or from the accidental entrance of 
foreign matters into the larynx, or from gradual failure of the respiratory 



208 



SPECIFIC FEBRILE DISEASES. 



acts and consequent asphyxia, or from enfeeblement of the heart's action, 
which is attended with remarkable slowness, or rapidity or irregularity of 
the pulse and tendency to syncope. Occasionally death is due to convul- 
sions or coma. In reference to diphtheritic paralysis M. Duchenne points 
out, that sensation and motion are usually simultaneously affected, but that 
the impairment of sensation tends to preponderate over that of motion. 
The paralyzed muscles retain their electric contractility, their bulk, and 
their healthy texture. 

In speaking of diphtherial albuminuria we remarked that it is usually 
one of the early phenomena of the disease. It must be added that it some- 
times comes on again, or for the first time, during the paralytic stage. 

Morbid anatomy and pathology — The morbid changes which attend 
diphtheria are almost limited to the circumscribed inflammations which 
have already been discussed. In most cases the affected parts are con- 
gested, swollen, and infiltrated with leucocytes and other inflammatory 
matters ; and, when the inflammation extends deeply, extravasations of 
blood and foci of suppuration, terminating in distinct abscesses, occasion- 
ally appear. The inflamed surface secretes abundant thin mucus ; and 
soon an opaque layer forms upon it. This increases by additions to its 
under surface and to its edges, and is attached to the subjacent mucous 
membrane, partly by general adhesion, partly by prolongations into the 
mucous and other follicles. In the first instance it consists only in the 
inflammatory proliferation of the epithelial cells, which become cloudy and 
are apt from the shrinking of their protoplasm to assume a stellate form, 
the resulting interstices being probably occupied by mucus. This appears 
to be its permanent condition in the pharynx. But in the air-passages a 
fibrinous exudation takes place before long at the surface of the membrana 
limitans, between it and the modified epithelial layer which it displaces, 
and coagulating there forms a more or less distinctly laminated network 
of fibres which entangle leucocytes but very rarely distinct epithelial ele- 
ments. Under these circumstances the superficial cellular lamina under- 
goes gradual disintegration and disappears, and thus the diphtheritic mem- 
brane at length becomes purely fibrinous. Many lowly vegetable organisms 
have, as might be supposed, been detected in it. It is not clear that any 
of them can be justly regarded as specific. Heuter, Oertel, and some other 
observers, however, maintain that the contagium of the disease consists in 
certain forms of bacteria, which they describe as existing in great abund- 
ance not only in the diphtheritic exudation, but in the lymphatic spaces 
of the subjacent corium. The membrane varies considerably in thickness 
and consistency, and when very thick, its superficial parts are apt to be 
pulpy or flocculent. Its detachment often exposes an excoriated surface, 
and sometimes distinct ulceration. Occasionally gangrene occurs. We 
have pointed out the localities in which diphtheritic membranes are chiefly 
formed. It remains to say that, when they extend into the nose or larynx, 
they adapt themselves accurately to irregularities of surface, and form 
complete solid casts of such diverticula as the sacculi laryngis ; and that, 
when they involve the bronchial tubes, they extend sometimes to their 
finest ramifications, forming arborescent laminated casts. It is mainly 
when the air-passages are invaded that collapse of lung and lobular pneu- 
monia take place, and, in children, interlobular emphysema, going on, it 
may be, to general emphysema. The only other organs ordinarily present- 
ing obvious morbid changes are the kidneys. These may be enlarged, 
and somewhat pale, and on microscopic examination may present granular 



DIPHTHERIA. 



209 



or fatty deposits in the renal cells, with hyaline casts occupying the canals 
of some of the tubules. In malignant cases, besides intense local mischief, 
hemorrhages take place beneath the serous and mucous membranes and 
into the substance of the lungs, heart, kidneys, and other organs ; and 
sometimes the muscular tissue of the heart presents granular or fatty 
changes. The blood has been said to be distinctly modified in character ; 
but this is certainly not always the fact ; and even in the worst cases 
fibrinous clots may be discovered in the cavities of the heart. 

That diphtheria, like the exanthemata, is a specific disease affecting the 
system generally can scarcely be doubted ; its symptoms and progress, and 
especially its paralytic sequelae, all attest the truth of this view. There 
may still, however, be a doubt as to whether the primary diphtherial patch, 
the formation of which attends the first onset of the disease, is a localized 
outcome of the general disorder and analogous therefore to the rash of 
variola ; or whether it is to be regarded as the direct result of inoculation, 
and analogous therefore to the inoculated variolous pustule. In what way 
the diphtherial poison induces paralysis is a problem which does not at 
present admit of solution. The lesion, however, whatever its exact nature 
may be, is evanescent, and seems mainly to involve the medulla oblongata 
and neighboring parts. 

Treatment The treatment of diphtheria is a subject of much interest 

and importance, and not the less so that great variety of opinion has 
prevailed even in regard to points of vital moment. One of the most re- 
markable features in the disease is its tendency to produce anaemia and 
exhaustion, and death by asthenia. Such being the case, it is scarcely 
necessary to say that depletory measures cannot be adopted without great 
risk. Indeed it is now almost universally admitted that the general 
treatment should be directed to the maintenance of the bodily powers. 
To this end, nourishment by appropriate kinds of food, and the use of 
such tonic medicines as the patient can bear, must be firmly enforced. 
The liquid or pulpy foods generally administered in acute febrile disorders 
are suitable here ; for medicine it is fashionable to prefer the solution of 
perchloride of iron, and doubtless the preparation is a valuable one; but 
there is no reason why other preparations of iron should not be given, or for 
the avoidance of quinine and other vegetable tonics. By some, chlorate 
of potash, or this with the addition of small quantities of hydrochloric 
acid, is strongly advocated. For local treatment of the affected mucous 
membrane various agents have been proposed. Bretonneau, and Trousseau 
following him, strongly recommended the free application of undilute hydro- 
chloric acid ; others prefer strong solution of nitrate of silver or of bicar- 
bonate of soda, or pure tincture of the perchloride of iron, or creasote. 
Again, other practitioners regard the use of strong caustics as useless, if 
not injurious, and prefer to wash out the throat or have it gargled with 
solution of chlorate of potash, alum, or the like ; and undoubtedly the 
administration of ice in small lumps is in many cases very grateful. 
Remedies to the nose must be applied either in the fluid form by means 
of a syringe or nasal douche, or as a powder by insufflation. The larynx 
must be treated, either by insufflation, by 4 swabbing,' or by the use of the 
vaporizing apparatus under the guidance of the laryngoscope. Emetics, 
which were formerly and are still often given for their supposed specific 
effects on inflammations of the respiratory mucous membrane, have been 
regarded as remedies of the utmost importance in croup, and therefore in 
all cases in which the diphtherial membrane tends to pass into the larynx. 
U 



210 



SPECIFIC FEBRILE DISEASES. 



They are sometimes useful, indeed, but chiefly if not entirely by the me- 
chanical influence of the vomiting which they induce, in promoting the 
expulsion from the larynx and trachea of the mucus, and even of the false 
membrane which obstructs them. They must, therefore, be regarded 
mainly as local remedies. Of emetics, it is best to give those that act 
rapidly without inducing much depression ; for these reasons large doses 
of ipecacuanha or of sulphate of copper are preferable to equivalent doses 
of antimony. 

As soon as distinct implication of the mucous membrane of the larynx 
or trachea occurs, the question of the performance of tracheotomy will 
necessarily and properly present itself. The extreme fatality of croup if 
left to itself, the little influence which drugs exert over its progress, and 
the fact that death is in the great majority of cases directly due to the 
affection of the larynx and trachea, render in many cases the opening of 
the trachea our only hope. It is doubtless generally difficult to decide at 
what moment the operation becomes imperative. Here the physician must 
do what he thinks best according to his own judgment, bearing in mind, 
however, that it is much better to perform the operation too early than too 
late, and that he ought not to be deterred from doing it by the supervention of 
one of those deceptive intervals of calm and tranquil breathing, which are 
so common even while the disease is hastening to its fatal issue. Further, 
it is better to operate even when life seems ebbing away, or the patient is 
moribund, and in the face of every discouragement, than to let him die 
suffocated before one's eyes without making an effort to save him. Trous- 
seau's vast experience of this treatment of croup gives an average of one 
successful operation out of four ; he points out, however, that tracheotomy 
in children under two is almost never successful. Other writers (chiefly 
foreign) record results at least equally encouraging. 

In the treatment of convalescence, and in that of the consecutive para- 
lysis, all efforts should be directed to improve the general health of the 
patient and to give him strength. With these objects, change of air, 
tonics (especially quinine and iron), good diet, and a fair proportion of 
stimulants, are most important. Other agents may be serviceable in 
promoting the cure of the paralysis, especially strychnia, galvanism, and 
friction. 

Lastly, looking to the established fact that breaches of the cutaneous 
surface have a great aptitude to become the seat of diphtherial inflamma- 
tion, it should be regarded as a fundamental rule never to employ blisters 
or other remedies calculated to produce sores. 



XVIII. ENTERIC FEVER. {Typhoid Fever. Abdominal Typhus?) 

Definition A febrile disorder, characterized by an inflammatory affec- 
tion of the agminated and solitary glands of the intestines, gastro-intestinal 
disturbance, and a peculiar rash. 

Causation and history Enteric fever is a disease of world-wide preva- 
lence, occurring for the most part in an endemic form, but occasionally 
assuming the proportions and the behavior of a genuine epidemic. It 
seems to have no special connection either with overcrowding, poverty, or 
ill-health, and indeed to attack the denizens of town and country, rich 



ENTERIC FEVER. 



211 



and poor, healthy and ailing, with singular impartiality. Sex is without 
influence over it ; but children and young persons are much more liable to 
it than adults, and these than such as are of advanced age. Dr. Murchi- 
son's investigations show that more than half the total number of cases 
admitted into the London Fever Hospital during ten years occurred in 
persons between the ages of fifteen and twenty-five ; more than a fourth 
in persons under fifteen ; one-tenth in persons between twenty -five and 
thirty ; and that from the latter age onwards the numbers rapidly dimin- 
ished. Considering, however, how few children attacked with enteric 
fever are likely to become, hospital patients, it seems not improbable that 
the tendency to contract the disease is pretty nearly equal at all ages up 
to about twenty-five, and from that epoch it rapidly and uniformly dimin- 
ishes. Undoubted cases have been recorded at various ages between 
seventy and ninety. Dr. Murchison also shows, from the records of the 
Fever Hospital, that enteric fever prevails chiefly in October, November, 
September, and August, and that it is at its minimum in April, May, 
February, and March ; and he confirms the general belief that its preva- 
lence is augmented by excessive heat of weather, and diminished by con- 
tinuous low temperature. There is reason to believe that persons newly 
arrived in districts in which enteric fever is endemic are more likely to 
take it than those who have resided there for some time. 

The confusion which prevailed up to within a recent period in regard 
to typhus and enteric fevers rendered any exact knowledge of their causa- 
tion impossible. Since, however, they have been recognized as distinct 
and specific diseases, much light has been thrown upon the subject. It 
has been proved, indeed, apparently beyond all cavil, that enteric fever is 
above all fevers the fever of fecal decomposition ; that it occurs only among 
those who are exposed to the influences of defective drains or foul and over- 
flowing cesspools, especially when these are so situated as to pour forth their 
fetid gases into the interior of houses, or to contaminate by their emana- 
tions, their soakage, or their leakage, water and other articles used for 
food. In opposition to this view, it has been asserted that persons who 
work in the sewers are never attacked with enteric fever ; but, even if this 
were the fact (which it is not), it would weigh nothing against the positive 
evidence on the other side, which has been furnished of late years by re- 
peated scientific investigations into the causes and circumstances of local 
outbreaks of the disease all over the country. The subject of its etiology 
is not exhausted, however, in the above remarks. It is admitted by pro- 
bably all physicians that enteric fever is not, in the usual sense of the 
term, contagious; that it is not conveyed from one person to another per- 
son by the touch or by the breath ; and that attendants on the sick rarely 
if ever take the disease from them; yet it is quite certain that the immi- 
gration of a patient, suffering from enteric fever, into an uninfected locality 
not unfrequently leads to an outbreak there. We have pointed out that 
it vseems not to escape with the breath, or from the skin; and, it must be 
added, that if it escapes with the feces in an active form it is difficult to. 
understand how the nurses, and other persons brought into relation with 
the sick, so constantly escape infection. It has been observed, however,, 
over and over again, that the feces, which are probably at first wholly 
ineffective, become, in the course of putrefaction, virulent in a high degree, 
and impart their infectious properties largely to the contents of cesspools- 
and sewers, and thence to well and other waters, with which the former 
happen to communicate. In many cases, indeed, the. source of an enteric- 



212 



SPECIFIC FEBRILE DISEASES. 



fever outbreak has been distinctly traced to the water of a well, into which 
there has been percolation from a neighboring cesspool recently contami- 
nated with the evacuations of a patient suffering from that fever; and 
occasionally, also, groups of cases seem to have been distinctly referable 
to body-linen and bedclothes befouled with typhoid evacuations, which have 
been allowed to accumulate and remain unwashed. It seems clear, there- 
fore, that persons suffering from enteric fever discharge in their fecal 
evacuations (as do cholera patients) some specific but at the time innocuous 
organized substance; which, after its escape from the body, and under 
suitable circumstances, increases and at the same time becomes virulent, 
diffusing itself throughout the fluid media to which it gains access, and 
imparting to them its specific properties. The question then arises, does 
the specific poison of this disease, which is certainly developed from the 
stools of patients suffering from it, also arise spontaneously, or rather inde- 
pendently of such stools? The question is by no means easy to solve. Dr. 
Murchison especially argues forcibly in favor of its origin independently 
of the disease which it generates. Dr. Budd and others argue with equal 
vehemence in support of the opposite hypothesis. We incline strongly to 
the latter view, and, in accordance with it, are disposed at present to regard 
the essential cause of enteric fever not as a mere inorganic or even organic 
result of decomposition, but (like other contagia) as an organized living 
particle which has special endowments and unlimited powers of multipli- 
cation ; not as the product of healthy bowels or of ordinary decomposing 
ordure, but as a specific virus yielded by the bowels of patients suffering 
from enteric fever, and probably by them alone. A further question here 
presents itself — namely, by what route does the virus gain admission into 
the system? It is certain that in many cases it is received into the alimen- 
tary canal ; it is thus that the disease is imparted by contaminated water, 
and by milk to which contaminated water has been added. It is generally 
believed also that it may be inhaled with the breath, and that it is thus 
that the effluvia of cesspools and drains act in producing the disease. On 
the whole, there is reason to suspect that the virus in all cases enters the 
system at the surface of the alimentary mucous membrane, and that the 
intestinal lesions are to be regarded as points of inoculation. 

One attack of enteric fever is believed to confer immunity against sub- 
sequent attacks. If, however, this be so, the immunity is much less perfect 
than in the case of the infectious fevers generally; for many second attacks 
have been recorded; and, moreover, true relapses are far more common 
than in other allied specific disorders. 

Symptoms and progress The mode of attack and the initiatory symp- 
toms of enteric fever present great variety. In exceptional cases its in- 
vasion is as sudden and well-marked as that of typhus, the symptoms 
moreover resembling those of that disease. But much more commonly it 
comes on so insidiously, w 7 ith undefinable feelings of malaise, or slight 
feverishness, or failure of appetite, and strength, or some degree of gastro- 
intestinal disturbance, extending over some days, that the patient is quite 
unable to fix the date of the commencement of his illness. During the 
early period of enteric fever, the patient suffers in a greater or less degree 
from the following symptoms : — irregular chills and flushes of heat ; in- 
creased frequency of pulse, and elevation of temperature ; lassitude, and 
aching in the limbs ; thirst and loss of appetite, with morbid redness or 
coating of the tongue ; and headache or heaviness of the head, with tendency 
perhaps to drowsiness by day, to wakefulness, restlessness, and dreaming at 



ENTERIC FEVER. 



213 



night time. Vomiting and diarrhoea, with abdominal pain, and tender- 
ness in the csecal region, are generally associated with the above symp- 
toms, and, though sometimes absent, are often the very earliest and gener- 
ally the most striking of the phenomena which attend the earlier period 
of the disease. During the first week of the fever, although the symptoms 
gradually increase in severity, the patient is very often not confined to his 
bed. At the beginning of the second week, however, unless the case be 
exceptional either in its mildness or in its intensity, the symptoms become 
more fully developed and assumes a more characteristic aspect. The fever 
reaches its acme ; the skin is generally hot and dry, but liable to break 
out in perspirations ; the pulse still increases in frequency, as also do the 
respirations, and not unfrequently there is some degree of cough ; the 
tongue may continue clean or become coated with a moist fur, but gener- 
ally, whether coated or clean, tends to get dry and to present cracks, mostly 
transversal, upon the dorsum ; the vomiting has very probably subsided, 
but the thirst and anorexia continue, and there may be some difficulty in 
swallowing and speaking in consequence of soreness of the throat ; the 
patient sleeps badly; and occasionally, but by no means in all cases, de- 
lirium comes on, especially at night time and between waking and sleeping. 
It is about this time, too, that the rash which is peculiar to the disease first 
makes its appearance. It consists in lenticular rose-colored spots, dis- 
tinctly elevated and sensible to touch, disappearing on pressure, and vary- 
ing when f ully formed from half a line to a line and a half in diameter. 
Though generally rising above the general level in the form of segments 
of spheres, they occasionally become vesicular in the centre and thus 
more or less distinctly acuminated. They are rarely numerous, and al- 
ways appear in successive crops — those of each crop attaining their full 
development, and disappearing, in the course of two, three, or four days. 
Thus, spots of various ages are generally present and intermingled at one 
and the same time. In perhaps one-fourth of the total number of cases 
no spots are ever discovered ; and in the remainder their number may 
vary from a dozen or less up to many hundreds. They are chiefly devel- 
oped on the chest, abdomen, and back ; but occasionally are observed on 
the face and extremities. At this time too the intestinal symptoms usu- 
ally become pronounced ; the abdomen is more or less tumid ; tenderness 
and pain manifest themselves more distinctly in the right iliac region, 
where also on pressure gurgling may be detected ; and the bowels become 
loose— open three, four, or a dozen times a day, and discharging liquid 
yellow stools which have been likened, not unaptly, to pea-soup. From 
the condition above described the patient may gradually recover, but in 
a large proportion of cases he passes, in the course of the second week 
(probably towards its close), into a typhoid condition. The elevation of 
temperature continues ; the rash still comes out ; the diarrhoea persists ; 
the tongue becomes dry and brown and traversed by deep fissures, the lips 
and teeth covered with sordes, the pulse quicker and more feeble ; the 
general prostration increases; complaints of headache and pain cease; the 
mind grows dull and apathetic ; drowsiness and delirium (sometimes vio- 
lent, sometimes busy, sometimes muttering) supervene ; and bed-sores 
tend to form. Blood, in greater or less quantities, is now not unfrequently 
passed with the stools. Finally, if the case be going on unfavorably, 
tremors, subsultus, and involuntary passage of the evacuations come on, 
the somnolence or delirium passes into coma, and death ensues. If, on 
the other hand, the case be likely to do well, convalescence commences 



214 



SPECIFIC FEBRILE DISEASES. 



usually in the course of the third or fourth week. The change is in general 
quite gradual. The fever abates, the pulse falls, the cerebral symptoms 
pass away, the tongue cleans, the appetite reappears; the diarrhoea ceases, 
and the strength returns. The progress of convalescence is, however, 
always slow, and the patient often does not regain his former health until 
after the lapse of many months. Occasionally, when convalescence seems 
to be fairly established, a relapse takes place, attended with the rash and 
all the other symptoms and phenomena which characterized the original 
attack. A second relapse may follow. 

The foregoing account applies, for the most part, fairly well to the ordi- 
nary run of well-marked, uncomplicated cases of enteric fever. No dis- 
ease, however, is attended with greater variety of symptoms, or presents 
more frequent and greater departures from the typical character. It is 
desirable, therefore, to discuss briefly the various phenomena of the dis- 
ease, and its varieties. 

The pulse varies greatly in frequency. Occasionally, in very mild cases, 
it scarcely exceeds the normal throughout the whole course of the illness. 
In other cases, however, it mounts (in dependence very much on the 
severity of the case) to 90 or 100, and from this to 120, 140, or more, 
and becomes very feeble. It is generally quicker in the evening than in 
the morning, and in the typhoid stage than in the earlier period. Other 
things being equal, rapidity of pulse implies severity of attack. It is 
curious, however, that even during the presence of marked fever the pulse 
may at times sink below 50 or 60. In one of Dr. Murchison's cases it 
fell to 37. 

The respirations are generally more or less accelerated, especially with 
the advance of the fever, and not unfrequently some little cough is present. 
These symptoms are necessarily greatly aggravated when (as not unfre- 
quently happens) bronchitis or pneumonia becomes developed. Then also 
the surface is apt to get dusky, and the local signs of the complication 
manifest themselves. 

The character of the tongue varies. In some cases this organ remains 
a'most normal throughout the illness, or is merely a little redder and drier 
than natural, or presents the slightest possible increase of epithelium only. 
More commonly it is covered, except at the margins, with a whitey-brown 
fur which tends to become dry, or it has a dry, glazed, morbidly red char- 
acter, and in either case is apt to present transverse cracks which are often 
of considerable depth. The throat is not unfrequently congested and sore; 
and there may even be inflammation of the tonsils at an early period. 
Sickness is one of the most common of the initiatory symptoms, and is 
sometimes exceedingly severe. It may even last throughout the whole 
illness. Thirst and loss of appetite are almost invariably present. Diar- 
rhoea is seldom absent, and is often very severe. Not unfrequently it 
prevails from the beginning ; but in many cases it does not come on 
till the second week, or even later ; and sometimes there is constipation 
throughout, or the patient has an occasional loose stool only. The mo- 
tions usually have the appearance and consistence of pea-soup, are alkaline, 
and often offensive; in the course of the second, third, or fourth week they 
may contain blood. The progress of the fever is generally attended with 
some abdominal pain, tenderness and gurgling in the right iliac fossa, and 
more or less flatulent distension of the belly. 

In the early part of the disease the urine is scanty, dark-colored, and of 
high specific gravity; later on it becomes pale and copious, and its specific 



ENTERIC FEVER. 



215 



gravity falls. There is almost always a large increase in the amount of 
urea and uric acid, especially at the commencement; and the chlorides are 
diminished. Albumen is not present in more than one-third of the total 
number of cases, and occurs for the most part in very small quantity and 
seldom before the third week. 

The skin, though for the most part dry, is apt to become moist, espe- 
cially in the morning; and during the latter part of the second, or in the 
third week profuse perspirations may occur. The cheeks, especially after 
meals or during the febrile exacerbations, are often flushed. The rash, 
which has already been described, continues by successive outbreaks for 
one, two, or three weeks. During convalescence perspirations are often 
very copious, and sudamina generally appear on the chest. 

The fever as indicated both by the thermometer and by symptoms, is 
always of a remittent character, presenting morning falls and evening ex- 
acerbations. The temperature begins to rise about noon and attains* its 
maximum between 7 p.m. and midnight. After midnight it gradually falls, 
the lowest point being usually attained between 6 and 8 a.m. In uncom- 
plicated cases these daily alternations are almost constant, the difference 
between the morning and evening temperature varying from one to two or 
three degrees, or even more. The rise begins from the first day of illness, 
and gradually increases by daily waves until, on the fourth or fifth day or 
about the end of the first week, it attains its greatest elevation, which 
varies in different cases between 104° and 106°. From this period up to 
about the twelfth day there is but little change. Then, if the case be mild, 
the morning falls become lower and of longer duration, to be followed 
shortly by a corresponding decline in the evening rises ; and gradually, as 
convalescence becomes established, the morning and evening temperatures 
approximate until they attain their normal level, or even sink below it. 
If, on the other hand, the case be severe and the commencement of con- 
valescence be delayed, the temperature still continues high, and the morn- 
ing remissions often become less marked than they had been. Again, if 
in the course of the disease serious complications arise, the usual course of 
the thermal variations is modified. Profuse diarrhcea, epistaxis, or intes- 
tinal hemorrhage causes the temperature to fall ; as also does the condition 
of collapse, however produced. Pneumonia causes the temperature to rise, 
and modifies its diurnal variations. Sometimes it rises before death to 
108° or even to 110-3° independently of complications (Wunderlich). 

As regards the organs of sense : singing in the ears and deafness are not 
uncommon ; the conjunctivas are seldom congested ; the pupils are usually 
dilated; epistaxis is of frequent occurrence. Most patients complain, at 
the beginning of the disease, of giddiness and headache, and of more or 
less pain and sense of lassitude in the limbs. There is often wakefulness 
at night ; sometimes, on the other hand, there is somnolence, and this not 
unfrequently precedes delirium. Delirium is a variable symptom ; in 
many cases it never occurs ; in many it is slight, and shows itself only 
between waking and sleeping ; in severe cases it usually comes on about 
the middle or end of the second week, and is then apt to vary in character 
and duration. It may present all the characters of the delirium of typhus ; 
but, as Dr. Murchison remarks, it is more frequently of the violent and 
noisy kind than in that disease. In rare cases the invasion of the fever is 
attended with maniacal excitement. Coma occasionally supervenes before 
death. Convulsions are not usual; but are more common in children than 
adults ; they generally come on late, and frequently prove fatal. Muscular 



216 



SPECIFIC FEBRILE DISEASES. 



weakness is always present, but not so marked as in typhus; nevertheless, 
in the later stages of severe cases, tremors and subsultus are common. 
Occasionally there is muscular rigidity. 

Enteric fever presents itself in many forms, and has been and still is 
frequently confounded with other diseases. It is especially important to 
know, that, for the most part, cases of so-called 'infantile remittent fever,' 
' worm fever,' 'gastric fever,' and ' bilious fever,' are cases of this affection. 
In the mildest form of the disease the patient perhaps complains only of 
slight feverishness and weakness, with loss of appetite, and more or less 
diarrhoea or irregularity of the bowels, and probably goes about his ordinary 
avocations, or at all events does not take to his bed, and, if no complica- 
tion supervenes, recovers at the end of three or four weeks. In other cases 
the disease is much more severe in character, and its progress is more or 
less distinctly in accordance with the account we have already given ; the 
attack is one of well-marked enteric fever, but varies according to the rela- 
tive prominence of certain of the symptoms, such, for example, as vomit- 
ing, diarrhoea, thoracic symptoms, hemorrhage, and delirium. In other 
cases, again, the attack is from the beginning of exceptional severity, and, 
as in analogous cases of scarlet fever and other like affections, the patient 
dies, poisoned apparently and in a state of collapse, within the first week, 
sometimes on the first or second clay. 

Much of the danger which attends enteric fever depends on the compli- 
cations which arise in its progress. The most important of these are in- 
testinal hemorrhage, perforation of the bowels with peritonitis, and pneu- 
monia or bronchitis. 

It has already been pointed out that intestinal hemorrhage is not unfre- 
quent. It may occur at almost any period of the disease, but is most 
common from the middle or end of the second week to the end of the 
fourth. It may be due, in cases where there is a general hemorrhagic 
tendency, to oozing from the mucous membrane ; but far more commonly 
it takes place from the surfaces or edges of the intestinal ulcers. It has 
no necessary connection with the extent or size of the ulcers, or with the 
presence or absence of diarrhoea, or indeed with the mildness or severity 
of the patient's previous symptoms. The hemorrhage may be scanty, or 
so copious as to cause speedy death by syncope ; and the blood which 
escapes may be fluid or clotted, black, or the normal color of blood. 

Peritonitis is one of the most frequent causes of death in enteric fever, 
and, like intestinal hemorrhage, has no necessary dependence on either the 
severity of the case or the urgency of diarrhoea. In the vast majority of 
cases it is due to perforation of the bowel in the floor of one of the intes- 
tinal ulcers, and is therefore sudden and unexpected in its onset. Not 
unfrequently perforation occurs in patients who have never taken to their 
beds ; who are then seized, without warning, with intense abdominal pain, 
tenderness, and distension, together with vomiting, collapse, thoracic res- 
piration, and other symptoms of acute peritonitis. In such cases the 
nature of the complication is manifest. When, however, it takes place 
in patients who are already in a typhoid condition, the indications are very 
apt to be overlooked. Yet, even in these cases, there may be more or less 
evident abdominal pain and other local signs of peritoneal inflammation ; 
but very often the diagnosis must be made to rest mainly on the sudden 
supervention of collapse, with first a fall and subsequently a rise of tem- 
perature, increased rapidity and feebleness of pulse, hurried and thoracic 
respiration, duskiness of surface, copious perspirations, and flatulent dis- 



ENTERIC FEVER. 



21T 



tension of the abdomen or tympanites. Indeed it may be said generally 
that the sudden occurrence in the course of enteric fever of symptoms of 
intense collapse, even when no direct evidence of abdominal inflammation 
is present, points to perforation. Perforation of the bowel may occur in 
patients of all ages, but is more common in males than in females. It 
cannot take place until ulceration has commenced, and, as might be sup- 
posed, is more common when ulceration is advanced than when it is begin- 
ning. Hence, although it occasionally happens during the second week 
(more especially towards its close), it is much more common during the 
third, fourth, and fifth weeks; and, indeed, all risk has not ceased until 
the expiration of two or three months. It may arise, therefore, during 
the period of convalescence ; and even after apparently complete restora- 
tion of health. Death almost invariably follows this lesion; and generally 
occurs within a couple of days, sometimes in the course of a few hours. 
But occasionally life is prolonged for a week or two ; in which case the 
peritonitis becomes circumscribed and an abscess forms. A few cases of 
recovery after the evacuation of such an abscess have been recorded. Dr. 
Murchison calculates that no less than one-fifth of the total number of 
deaths from enteric fever are due to perforation of the bowels. 

Bronchitis is often present in a slight degree ; but occasionally it gets 
severe, and may be so at any stage of the fever. The symptoms of bron- 
chitis are then added to those of the primary disease and mask them. So 
pneumonia, mainly lobular, may creep on insidiously at any time, but 
most commonly appears during the third or fourth week. It is usually 
connected with the hypostatic congestion of the lungs which is generally 
present in a greater or less degree ; and hence occupies mainly the back 
and basal portions of one or both lungs, and may fail to be detected 
unless the attention of the physician be specially attracted by the presence 
of symptoms indicating thoracic mischief. Pleurisy also ending in empy- 
ema is not unfrequent. 

Many complications and sequela? are described besides the above ; but 
they are, for the most part, /Unimportant or rare. We will enumerate a 
few of the more important. Ulceration of the larynx or trachea is de- 
scribed by various good observers, but is certainly not common. Throm- 
bosis of the veins, leading to oedema, frequently arises, especially in con- 
nection with the lower extremities. Bed-sores are very apt to form on 
the sacrum and other parts which are exposed to pressure or irritation ; 
but, independently of such causes, gangrene occasionally attacks the mouth 
(noma), ears, penis, vulva, feet, corneas, and especially parts to which 
blisters have been applied, or which are already inflamed from other causes. 
Imbecility, mania, and other mental disorders occasionally follow on enteric 
fever, as they are. apt to do on most affections attended with extreme exhaus- 
tion. So also does prolonged marasmus or the development of tuberculosis. 
Pregnant women not unfrequently abort. But neither pregnancy nor par- 
turition appears to interfere with the prospect of recovery. 

There is probably no other disease in which death threatens from so 
many quarters, and in which it may occur at such diverse and unexpected 
times. It is due immediately either to asthenia, asphyxia, or coma, or to 
combinations of these. It may happen early in the disease, mainly from 
the intensity of the attack ; in which case there is generally more or less 
pulmonary congestion. But it more commonly occurs later, either from 
pneumonia or other pulmonary complication, from perforation and peri- 
tonitis, from intestinal hemorrhage, or from coma coming on in the course 



218 



SPECIFIC FEBRILE DISEASES. 



of typhoid symptoms. Again, it may ensue, during the period of conva- 
lescence, from one or other of the sequeke of the disease, or from sheer 
exhaustion. Enteric fever in hospital practice is fatal in about the same 
proportion as typhus — at the rate, namely, of about 15 or 16 per cent. 
But when we consider how large a number of mild cases occur, which are 
not only never admitted into hospital, but are not even recognized, it 
becomes obvious that the proportion of total deaths to total attacks must- 
be much smaller than the above figures imply. The percentage mortality 
varies little with age ; but, on the whole, the statistics of the London Fever 
Hospital show, that the death-rate is less below the age of 20 than in the 
later periods of life, and that it is highest in patients above 50. 

It is not generally difficult to distinguish between a case of enteric fever 
and one of typhus. The main clinical distinctions are furnished : first, by 
the invasion, which is generally sudden in typhus, insidious in typhoid ; 
second, by the rash, which is abundant, general, and of nearly simultaneous 
origin in typhus, scanty and coming out in successive crops in typhoid ; 
third, by the abdominal symptoms, which in typhus are usually vague, 
but in typhoid comprise the discharge of liquid yellow stools, intestinal 
hemorrhage, pain and tenderness in the ca?cal region, and tympanites ; 
fourth, by the temperature, which does not in typhus present the gradual 
rise with regular diurnal variations which are so characteristic of typhoid ; 
and, fifth, by the mode of convalescence, which is by crisis and rapid in 
typhus, but slow and followed by long-continued debility in typhoid. 
Many other distinctions of secondary value might be adduced. But it 
must not be forgotten that all may fail us, and that the discovery of the 
typical intestinal lesions after death may alone reveal the nature of the 
case which has been under treatment. 

Morbid anatomy. — Enteric fever is always attended with characteristic 
anatomical lesions, affecting the solitary and agminated glands of the 
bowels and the mesenteric glands in direct relation with them. These 
lesions consist in an apparently simple hyperplasia of the glandular ele- 
ments, in virtue of which the organs undergo rapid enlargement, and then 
either slowly subside, reverting to their normal condition, or undergo 
softening, suppuration, ulceration or gangrene. Under the microscope the 
lymphatic corpuscles are found to be increased in number ; and frequently 
hypertrophied or giant cells, containing groups of small corpuscles in their 
interior, may be discovered among them ; later on the cells get granular 
and fatty, and break down into granular detritus. The morbid process 
appears to begin with the first symptoms of the patient's illness ; at all 
events, it has been found well advanced in those who have died during the 
first few days. 

The intestinal lesions are in many cases limited almost entirely to the 
agminated glands, of which sometimes two or three only, sometimes all 
are involved. These gradually swell until they form oval plates from a 
line to \ inch thick, which present a more or less tumid margin, a reticu- 
lated or foveated but oftener more or less mammillated and smooth surface, 
and a consistence which is sometimes softer but more often denser, though 
more friable than natural. They generally attain their full development 
by the ninth or tenth day — sometimes a day or two earlier, sometimes a 
day or two later. And then they either undergo slow resolution or pro- 
ceed to ulceration. The latter process may commence from the surface at 
numerous points, and thence gradually invade and destroy the whole of 
the diseased mass; or, as more frequently happens, the patch sloughs at 



ENTERIC FEVER. 



219 



once in the greater part or the whole of its extent. The resulting slough, 
which probably from bile-staining soon assumes a yellow or brown hue, 
becomes soft, spongy, and tumid, and separated by a line of demarcation 
from the still living tissues, and after a short time comes away either in 
mass or in successive fragments. The separation of the slough generally 
occurs between the fourteenth and twenty-first day, but may not be fully com- 
pleted for another week. The resulting ulcer varies in character. Usually 
its form is oval, or round; its margin thick and vertical, as if made by a 
punch, and more or less congested ; its floor pretty smooth and formed of 
the submucous tissue. Sometimes, however the edge becomes more or 
less extensively undermined, and then perhaps intensely congested, and 
the floor irregularly excavated and flocculent, and formed partly of the 
exposed muscular coat, partly, it may be, of the peritoneal membrane 
only. Cicatrization does not usually begin before the end of the third 
week, and probably, as a rule, is completed in about a couple of weeks 
more. But the process may be delayed, either from mere sluggishness, or 
in consequence of a kind of phagedenic extension of the ulcer, or by other 
circumstances, and hence may not be accomplished under two or three 
months. The cicatrices rarely if ever lead to serious contraction. 

The typhoid process as it affects the solitary glands is precisely similar, 
excepting that, the resulting tumors are much more numerous and much 
smaller— generally about the size of half a pea : and that, on the one hand 
resolution Avithout ulceration is more common, and on the other the ulcers 
which form are of insignificant dimensions and tend to heal more rapidly. 

The morbid process, whether it affect only the agminated glands or in- 
volve the solitary glands as well, is always most extensive and advanced 
in the ileum immediately above the ileo-ctecal orifice ; whence in both of 
these respects it gradually diminishes upwards. The solitary glands are 
rarely affected to a greater distance than two or three feet above the valve ; 
Peyer's patches rarely above the lower half of the ileum. The disease 
implicates the solitary glands of the large intestine in about one-third of 
the fatal cases, and is always most advanced in the caecum, rarely extend- 
ing below the ascending colon. Perforation takes place only in those ulcers 
which have already destroyed the muscular wall. But when the floor is 
thus formed of peritoneum only, it sometimes happens that local peritonitis 
occurs and causes adhesion between the affected portion of bowel and some 
neighboring organ, and thus averts the impending catastrophe. The actual 
perforation may be due to the forcible separation of such adhesions ; but 
more commonly, probably, it is the result of the simple accidental lacera- 
tion of the softened and unsupported serous covering. It occurs in the 
great majority of cases in the lower two feet of the ileum ; but it has been 
met with at least six feet above the ileo-caecal valve, and more rarely in 
the caecal appendage or in the colon. The peritonitis which results is in 
the first instance always general ; but not unfrequently when the rupture 
is small and but little fecal matter has escaped, this latter and the suppu- 
ration which it necessarily excites are found after death to be strictly con- 
fined by adhesions to a very limited space. It is this tendency to limitation 
which gives an element of hope in the treatment of these cases, and to 
which the very few recorded recoveries after perforation are due. Some- 
times the laceration is so extensive that large quantities of fecal matter are 
discharged at once into the peritoneal cavity. 

The mesenteric glands, especially those connected with the lower part of 
the ileum, enlarge from the beginning with Peyer's patches ; they some- 



220 



SPECIFIC FEBRILE DISEASES. 



times attain the size of a walnut, become soft and vascular, and at the 
end of either ten days or a fortnight undergo resolution, or soften, or sup- 
purate. Under the latter circumstances they not unfrequently dry up 
eventually ; sometimes, however, they induce peritonitis either by extension 
of inflammation, or by rupture into the serous cavity. Most other lesions 
in enteric fever, such as bronchitis, pneumonia, and pleurisy, have no spe- 
cific characters, and need no description. The spleen, however, is enlarged 
and congested; and it maybe added that when the patient dies during the 
ulcerative stage of the fever, the contents of the bowels are generally pea- 
soup-like, and the large intestines inflated with gas. 

Dr. Klein's 1 inquiries show that the smaller typhoid growths do not 
originate exclusively in solitary glands, but that they often arise in the 
lymphoid tissue of the mucous membrane. He also shows that the typhoid 
process whether taking place in the intestines or mesenteric glands is at- 
tended with hyperemia of vessels, increased development of lymphatic 
cells, and the development from these of giant cells, not unlike those of 
tubercle, and the rarefaction of the fibrous matrix. Further, he calls 
attention to the presence of a microscopical fungus in connection with the 
specific intestinal lesions. This is characterized by a distinct mycelial 
growth, by greenish spherical bodies two or three times as large as blood- 
corpuscles, and by micrococci or spores of extreme minuteness which occur 
singly or in couples, or in strings, or in irregular clusters. The fungus 
exists on the surface of the mucous membrane and within the tubular 
glands but it pervades the epithelium and is especially abundant in the 
lymphatic spaces and channels, and in the small veins. Similar bodies are 
discoverable in the diseased mesenteric glands. 

Treatment. — Knowing as we now do the source whence the contagion of 
enteric fever enters the system, it becomes our duty, nor is it difficult, to 
adopt suitable precautionary measures both against the contamination of 
water and atmospheric air, and against the exposure of persons to the in- 
fluence of media thus contaminated. Whenever typhoid patients are under 
treatment their evacuations should be disinfected with carbolic acid, Con- 
dy's fluid, or chloride of lime before they are emptied into the sewer or the 
cesspool ; and all articles of dress soiled by such evacuations should be 
similarly disinfected and washed. Water-closets and drains should be kept 
sound, clean, well flushed, and well ventilated, and all communications 
between drains and the interior of the house cut off by efficient traps. No 
water should be used for drinking or culinary purposes which has been ex- 
posed to sewage-contamination ; hence the water of superficial wells, espe- 
cially if these be near cesspools or sewers, should be looked upon with 
grave suspicion, as also should the water derived from streams or ponds 
receiving drainage, and that from cisterns or butts communicating by 
waste-pipes with closet-drains. If such waters must be drunk, they should 
first be boiled and filtered. It must not be forgotten that milk, from the 
presence of water which has been fraudulently or otherwise added to it, 
has on several occasions been the vehicle for the communication of the 
disease. 

Many remedies have been employed for the cure of enteric fever; 
amongst others mineral acids, antiseptics — such as chlorine, hyposulphites, 
carbolic acid and creasote — and emetics ; other remedies, again, have been 
used with the special object of reducing the fever — such are quinine in large 

1 Report of Medical Officer of the Privy Council, New Series, No. vi., pp. 80 et seq. 



ENTERIC FEVER 



221 



doses (10 or 15 grains), salicylate of soda, actual refrigeration, and bleed- 
ing. The last practice has properly fallen into desuetude. The use of 
cold is often beneficial, especially in cases in which the temperature 
reaches or exceeds 104° ; it is best applied by means of baths, the temper- 
ature of which to begin with should be 10 degrees or more below that of 
the body, and then gradually reduced to about 68°, immersion being con- 
tinued for about half-an-hour, or until the patient's temperature, as ascer- 
tained in the mouth or rectum, has become sensibly reduced, or shivering 
comes on ; but cold or tepid sponging is also serviceable. Our chief aims, 
however, in the treatment of this disease must be to guard against and 
prevent the many sources of danger which attend it, and to relieve symp- 
toms as they arise. The condition of the bowels must be carefully watched, 
and under no circumstances must drastic purgatives be employed. There 
is no harm, perhaps, in giving a mild laxative, such as castor oil in small 
doses or rhubarb, during the first week of the disease and before ulceration 
has taken place; but even then it is generally sufficient, and on the whole 
certainly more safe, to employ enemata. Subsequently, enemata only 
should be resorted to. When diarrhoea is present it should be restrained 
either by tannic acid, lead and opium, sulphuric acid, the compound kino 
powder, or some such remedy, or by opium or morphia suppositories, or 
opiate enemata. Trousseau, Dr. George Johnson, and others think that 
the diarrhoea should not be restrained, regarding it as a curative effort of 
nature ; that view, however, is not generally accepted, and is, we think, 
erroneous and dangerous. When hemorrhage from the bowels takes place 
measures should be adopted to arrest it. Dr. Murchison has great faith in 
the use, under such circumstances, of turpentine, tannic acid, ergot of rye, 
or other forms of astringents. Hemorrhage occurring, however, during 
the first ten or twelve days is of little importance, and does not usually call 
for treatment. For the prevention of perforation, the avoidance of purga- 
tives, the arrest of diarrhoea, and the maintenance of a quiescent condition 
of the bowels, are of extreme importance; it is further necessary to pre- 
vent the patient from using muscular exertion, and from taking articles of 
food likely to upset the bowels. If signs of perforation manifest them- 
selves, our only hope lies in keeping the patient under the influence of 
opium or morphia — the dose and frequency of its administration being de- 
termined partly by the patient's age, but chiefly by its effects. Tympa- 
nites may be benefited by the use of stimulating enemata or hot fomenta- 
tions to the belly. Sickness may be relieved by the use of lime-water and 
milk, bismuth or ice, or by counter-irritation. Pulmonary complications 
should be guarded against by the maintenance of an equable temperature, 
and by the avoidance of draughts. When present they must be treated on 
general principles. The great tendency there is to the formation of bed- 
sores makes it very important to keep the patient scrupulously clean and 
dry, to take measures to obviate or relieve pressure, and, if precursory 
redness makes its appearance, to anoint the part with some stimulating 
and protective application. The diet should consist of fluid and easily 
digestible food given frequently (every hour or two), and in small quanti- 
ties. The best aliments are milk, gruel, barley-water, rice-water, and such 
like ; but arrowroot, sago, chicken-broth, beef-tea, and eggs are valuable. 
Stimulants are necessary when there is tendency to collapse, when typhoid 
symptoms are present, or when there is great debility. In many cases, 
however, though their administration in moderate quantities can do no 
harm, they are by no means absolutely needed at any period of the disease. 



222 



SPECIFIC FEBRILE DISEASES. 



Much care is necessary during convalescence. The great debility which 
endures so long demands the use of tonics, and an abundance of nutritious 
food. But the liability to perforation of the bowel (which may not cease 
until the end of two or three months) makes it specially important that 
the food should be easily digestible, and not of such a character as to 
derange the action of the bowels. Moreover, the liability to the super- 
vention of pulmonary inflammation and of tuberculosis renders exposure 
and fatigue particularly liable to be injurious. Change of air is often ex- 
tremely beneficial. 



XIX. EPIDEMIC CHOLERA. {Asiatic or Malignant Cholera.) 

Definition An epidemic disease, of which the attacks are very severe 

and rapidly fatal, characterized by copious discharge of watery fluid from 
the alimentary canal, suppression of the urine and other secretions, shrink- 
ing of the tissues, cramps, and extreme prostration. 

Causation and history — Epidemic cholera has been known in India for 
centuries, and probably from time immemorial. It is seldom entirely 
absent there, but at irregular intervals breaks out into wide-spread epi- 
demics. The first Indian outbreak which specially interests us is that 
which, originating in the Delta of the Ganges in the year 1817, soon 
ravaged the greater part of Hindostan, and during the next ten or twelve 
years spread over nearly the whole of Asia, including the Burmese empire, 
China, Tartary, and Persia. In 1829 it commenced its progress through 
Tartary and Persia into Europe, and in that year it reached Orenburg. 
It then became temporarily arrested ; but subsequently took a fresh start, 
and still travelling slowly westwards it appeared in the spring of 1831 in 
European Russia and Poland : and in October invaded Hamburg, Berlin, 
and Vienna. In the same month cases were imported into Sunderland, 
and the disease remained endemic in this country for fourteen months. 
Having thus reached the northwestern angle of Europe, the epidemic di- 
vided into two branches, one of which crossed the Atlantic and appeared in 
Quebec in 1832, thence diffusing itself over the North American continent ; 
the other turned southwards, attacking successively France, Spain, Italy, 
and the Northern Coast of Africa. The disease did not finally leave Europe 
until the year 1837. Since the epidemic of 1817, numerous other epi- 
demics have occurred in India, and several times the disease has slowly 
spread thence to Europe and to this country — not, however, always taking 
the same route as on the first occasion. 

The first British epidemic was that, above referred to, of 1831-32, the 
second occurred in 1848-49, the third in 1853-54, and the last in 1865-66. 
On each of these occasions the disease was distinctly imported into this 
country by passengers or sailors coming direct from infected places, and 
its general prevalence was always preceded by local outbreaks in the sea- 
port, towns to which such infected visitors were admitted. The general 
history of these epidemics, so far at least as relates to England, has been 
that isolated outbreaks occurred in the autumn of the first year, that the 
disease died out with the approach of winter, and reappeared with extreme 
virulence in the later spring, summer, or early autumn of the second year, 
lasting for some two or three months, and then disappearing altogether. 



EPIDEMIC CHOLERA. 



223 



It might appear from this that its prevalence was largely determined by 
season; and, indeed, there is strong evidence to show that high temperature 
is on the whole favorable, and cold inimical to its spread. Yet, on the 
other hand, the disease has prevailed with the greatest severity in Moscow, 
Sweden, and other northern countries in the depth of winter. 

To what cause or causes is epidemic cholera due ? This is a question 
which has been the subject of innumerable discussions and investigations 
during the last fifty years. The horror which the disease occasions, the 
slowness yet certainty of its onward march, its sudden and capricious 
outbreaks, and its equally capricious subsidence and then total disappear- 
ance, all conspire to invest it with an atmosphere of mystery. Like in- 
fluenza, it is the very type of an epidemic disease ; and therefore, like 
epidemic diseases generally, has been largely held to be due to some at- 
mospheric or telluric condition, some peculiar ' epidemic constitution' which 
diffusing itself from country to country, gives to the prevailing maladies a 
choleraic character, and produces where local circumstances are favorable 
an outbreak of the fully developed disease. There is much to be said, no 
doubt, in favor of this view ; but the questions then naturally arise — ' on 
what does this epidemic constitution depend ?' and ' what are the local 
conditions which favor its operation ?' These questions are not easy to 
answer. We may point out, however, as bearing on them, — that, although 
heat and climate have (as has been stated) some influence over the propa- 
gation of the disease, there is no good reason to believe that moisture or 
drought, or excess or deficiency of electricity or ozone, affects it either 
one way or the other; that according to Pettenkofer, localized outbreaks 
of cholera are determined in great measure by peculiarities of soil — the 
ground must be porous and a superficial layer of it unoccupied by ' ground 
water' and penetrable by air ; that as shown by numerous observations, 
the disease is much more apt to prevail in low-lying districts than in those 
which are much elevated above the sea ; and that vegetable fungi, which 
have been detected by numerous observers in cholera stools, have often 
been assumed to pervade the atmosphere and to be the specific cause of 
cholera. These latter have been specially investigated by Hallier, who 
recognizes in the stools and vomit a form of urocystis consisting partly of 
membranous spore-cases containing yellowish or brownish spores, and 
partly of cells of extreme minuteness which he believes to have been devel- 
oped within these spores. These fungi he has cultivated in various ways ; 
and he believes that he has obtained from them forms of penicilium, mucor, 
and the like, all of which he regards as polymorphous conditions of one 
and the same fungus. It must be added, however, that this particular 
form of fungus has certainly not been recognized by most others who have 
been engaged in similar investigations. Lastly, in relation to the subject 
now under discussion, it may be pointed out that cholera has often been 
attributed to the accidental or designed poisoning of springs, and to the 
use of diseased cereals, especially rice, and even of unripe fruit. 

Again, in favor of the dependence of cholera on some miasm or epidemic 
constitution was the striking fact that, although cholera affected large 
numbers of persons within a short time, there was little evidence of its 
communicability by direct contagion. It was noticed, and has been con- 
stantly observed, that nurses and medical attendants seldom, if ever, take 
the disease from patients under their charge, and that the introduction of 
cholera patients into a general hospital is by no means necessarily followed 
by the spread of the disease to other patients. 



224 



SPECIFIC FEBRILE DISEASES. 



Nevertheless, it has always happened that the spread of cholera epi- 
demics has followed lines of traffic, showing that human intercourse, not 
winds, has been instrumental in their propagation. In every invasion of 
this country, the disease has first been distinctly imported into our seaport 
towns by the arrival thither of infected persons from infected localities ; 
and has thence been carried by like means to other localities in direct 
relation with them by railways or other lines of traffic, and has thus 
gradually become distributed throughout the country, not generally, but 
by local outbreaks. The fact that cholera though obviously not directly 
contagious, or at all events not directly contagious in a high degree, yet 
had some mysterious relation with the movements of mankind, and never 
broke out in any isolated country or town without having been distinctly 
imported into it by human agency, was manifestly opposed to most of the 
theories of its causation which have been previously referred to and had 
generally prevailed. Dr. Snow, now some years since, first shrewdly 
suspected that the cholera contagium was contained in the cholera evacua- 
tions, and that the disease was propagated by the entrance of minute 
quantities of such evacuations, for the most part through the medium of 
contaminated water, into the alimentary canal. And numerous subsequent 
investigations, some of the most remarkable being conducted by himself, 
have entirely confirmed the correctness of his prevision. The matter is 
so important that we may quote a few of the best established and most 
striking cases. 

The cholera epidemic of 1849 was specially severe in the south of Lon- 
don, which was supplied with drinking water mainly from surface wells 
and by two water companies, the Southwark and Yauxhall and the Lam- 
beth, which derived their water from the Thames — the one in the neigh- 
borhood of Hungerford Bridge, the other in that of Battersea Fields — and 
supplied it in a very imperfectly filtered condition. At that time all the 
sewers of London discharged themselves into the Thames, the water of 
which was consequently very foul. The cholera epidemic of 18o4 was 
also very severe in South London. But between 1849 and 1854 the Lam- 
beth Company had removed its intake from Hungerford Bridge to Thames 
Ditton, and consequently furnished an infinitely purer water than it had 
done in 1849; the other company continued to draw T its water from the 
neighborhood of Battersea Fields. At this time the two companies were 
acting in rivalry, so that in many streets their mains ran side by side, and 
houses, under the same sanitary conditions in other respects, received a 
different water supply. A careful investigation of the distribution of 
cholera in South London in this year, conducted mainly by Dr. Snow but 
with the assistance of the Registrar-General, gave the tollowing results: — 

Population Cholera Deaths Cholera Deaths 
ia IS5i. in 14 weeks. per 10,000. 

Houses supplied by Southwark Co. . 266,516 4,093 153 

" " " Lambeth Co. . . 173,748 461 26 

The facts were even more remarkable when examined in detail; inas- 
much as in streets and localities which both companies supplied the dis- 
ease singled out the houses furnished by the Southwark Company. 

During the same epidemic a remarkable outbreak occurred within a 
limited area, in the neighborhood of Golden Square, London, the facts of 
which were also examined into by Dr. Snow. There had been a few cases 
in the neighborhood during the month of August, including altogether up 



EPIDEMIC CHOLERA. 



225 



to the 30th nine deaths. On the 30th at least eight cases which ultimately 
proved fatal occurred ; on the 31st, fifty-six ; on September 1, one hundred 
and forty-three ; on the 2d, one hundred and sixteen ; on the 3d, fifty -four ; 
and then daily until the 9th, forty-six, thirty-six, twenty, twenty-eight, 
twelve, eleven ; after which the disease rapidly disappeared. No less than 
six hundred and sixteen persons were ascertained to have been fatally 
attacked with cholera within this area between August 19 and September 
30, of whom at least four hundred and fifteen contracted the disease 
between August 31 and September 4 inclusive. It would take much more 
space than is at our disposal to enter fully into details ; suffice it to say that 
Dr. Snow's investigations proved beyond the shadow of a doubt that this 
sudden and evanescent outbreak was distinctly due to the use of the sew- 
age-contaminated water of the Broad Street pump occupying the centre of 
the affected area, the water of which was held in great repute, and was 
largely drunk by those who lived in its neighborhood. 

Again, the epidemic of 1866 was remarkable in the fact that it was 
almost limited to a circumscribed area in the East of London, including 
Bethnal Green, Whitechapel, St. George's, Stepney, Mile End and Poplar, 
together with the suburban districts of Stratford and West Ham. The in- 
quiries of Mr. RadclifFe, conducted under the direction of the Medical Officer 
of the Privy Council, demonstrated with almost mathematical precision 
that the localization of the epidemic was almost entirely due to the dis- 
tribution to these districts of impure and unfiltered water by the East 
London Water Company. 

It must be assumed therefore as a fact that the choleraic poison, at all 
events in a large number of cases, is conveyed through the medium of foul 
drinking-water, and necessarily, therefore, by means of all articles of food 
or drink to which such water is added. But it still remains to ask — ' how 
does the poison reach the water, whence does it come, and what is it?' It 
would naturally be supposed that the choleraic poison is contained within 
the cholera stools ; and indeed there is plenty of evidence to show that the 
drinking of water directly contaminated with small quantities of rice-water 
evacuations has induced cholera ; and as regards the local outbreaks above 
adverted to, it is certain that the incriminated waters were contaminated 
with sewage, and that there was at least the probability that that sewage 
contained the evacuations of cholera patients. But, on the other hand, 
there is good reason to believe that the freshly passed stools are not spe- 
cifically noxious. Much, however, of what seems mysterious in reference 
to these matters appears to be explained by the important experimental 
inquiries first conducted by Professor Thiersch, and since repeated by Dr. 
Sanderson in this country. The experiments which yielded the most 
striking results were those performed on mice. It was ascertained by 
these gentlemen that when, under certain conditions, mice were fed with 
cholera evacuations, they were attacked with symptoms which proved 
rapidly fatal, and that both symptoms and post-mortem appearances had a 
very close resemblance to those of human cholera. The chief points of 
likeness consisted, in the rapidity and intensity of the disease ; in a re- 
markable lowering of temperature (sometimes as much as 20 degrees) ; in 
the accumulation in the intestines of thin fluid containing bacteria, other 
lowly organisms, and abundance of shed epithelia ; and in the discharge of 
loose stools from the anus. The method adopted by Dr. Sanderson to 
infect the mice was to soak pieces of filter paper in fresh cholera evacua- 
tions, or in the contents of the bowels of patients dead of cholera, to dry 
15 



226 



SPECIFIC FEBRILE DISEASES 



them, to ascertain by weighing the quantity of solid matter thus added to 
them, to cut them into pieces an inch square, to soak them in bacon fat, 
and then to administer them to the mice. The mice under these circum- 
stances ate them greedily. The consequences were — that of mice fed with 
paper prepared from evacuations which had not been allowed to stand 
more than twenty -four hours, or on the first day, 11 per cent, were affected; 
of those fed with paper prepared on the second day, 06 per cent. ; of those 
fed with paper prepared on the third day, every one ; of those fed with 
paper prepared on the fourth day, 71 per cent. ; and of those fed with 
paper prepared on the fifth day, 40 per cent. Paper prepared subsequently 
had no effect. These experiments show — that the cholera evacuations 
have little or no intensity of action when perfectly fresh ; that their viru- 
lence increases up to the third day, diminishing during the fourth and 
fifth days; and that they lose all specific properties after that date. It 
should be added, that the evacuations from the diseased mice produced 
the same effects on healthy mice as did true cholera evacuations ; and, 
further, that all experiments made by Dr. Sanderson in the month of 
November failed absolutely, probably, as he suggests, on account of the 
low temperature then prevailing. 

The application of the above results in explanation of the phenomena 
connected with the causation of cholera is obvious. And it is fair to con- 
clude from them, and from the other facts which have been adduced — that 
the specific poison of cholera is furnished by the discharges from the ali- 
mentary canal ; that these are not operative when completely fresh, but 
acquire virulent infectious properties in the course of the following two, 
three, four, or five days, and subsequently lose them ; that the poison of 
the disease is taken up by, or acts upon, the mucous membrane of the 
bowels, which it reaches through the mouth : and that, while undoubtedly 
it may be conveyed to the mouth under uncleanly circumstances from 
saturated bedclothes, and direct contamination of culinary utensils, food, 
or fingers, larger outbreaks of the disease are due to the inf ection of drink- 
ing water (well, pond, or river) with cholera poison derived from cesspools, 
sewers, or other such sources. 

There can be little doubt, from the fact of its active powers of multipli- 
cation, that the cholera poison is an organized contagium ; that one phase 
of its normal active existence is passed externally to the body ; but that 
that phase is commonly of short duration, and probably readily arrested or 
rendered innocuous by cold and other agencies. 

Symptoms and progress. — The duration of the incubative stage of cholera 
is not known certainly. It probably varies generally between a few hours 
and three days. The symptoms of invasion present considerable variety. 
In some cases an indefinable feeling of malaise, associated with noises in 
the ears and lowness of spirits, precedes all other symptoms. In a very 
large proportion of cases (either in succession to the last or arising inde- 
pendently) there is more or less looseness of the bowels (premonitory diar- 
rhoea) coming on a few hours, a day, or even two or three days, before the 
nature of the disease is distinctly revealed. Premonitory diarrhoea of even 
longer duration has not unfrequently been observed ; but in most such 
cases there is reason to suspect that the relation of the diarrhoea to the 
subsequent attack of cholera was accidental only. Lastly, in some instances 
the invasion of cholera is quite sudden. Omitting the premonitory symp- 
toms which have just been considered, the first indication of an ordinary 
attack of cholera usually consists in the sudden and uncontrollable evacu- 



EPIDEMIC CHOLERA. 



227 



ation (with or without pain) of an abundant loose stool, composed mainly 
of the proper contents of the alimentary canal in a fluid or semifluid state. 
To this succeeds a continuous or intermittent flux of fluid, at first bile- 
stained, but subsequently thin, colorless, or opaline, without fecal look or 
smell, and containing in suspension whitish flocculi. The amount of fluid 
thus discharged is sometimes enormous ; four or five pints, or enough to 
fill a chamber-pot, may be passed in the course of an hour or two. Sick- 
ness for the most part attends the diarrhoea, but generally comes on a little 
later. The matters first vomited are the ordinary contents of the stomach 
and of the duodenum ; but after these have been got rid of, the vomited 
fluid exactly resembles that which is flowing simultaneously from the anus, 
and may be almost as abundant. Shortly after vomiting and diarrhoea 
have become established, severe cramps, attended with agonizing pain, come 
on in the thighs and calves, in the arms, hands, feet, and parietes of the 
abdomen. And very speedily the patient falls into a state of extreme col- 
lapse — the so-called 'cold' or 'algide' stage; his tissues shrink ; his fingers 
and toes get shrivelled and corrugated, and his eyes sink into their sockets; 
his surface becomes more or less notably livid, and sometimes as blue as» 
that of a cyanotic patient — this change being especially noticeable in the 
hands, feet, cheeks, lips, around the eyes, and in the tongue, which looks- 
like a piece of lead ; his respirations grow rapid and shallow, and his voice 
hoarse or squeaking, feeble, and reduced almost to a whisper ; his pulse 
gets rapid and thready, and soon scarcely, if at all perceptible at the wrist or 
even in the brachial artery. At the same time his temperature falls ; his 
surface becomes cold and clammy, and sometimes covered with cold sweats ; 
and his tongue and breath also get manifestly cool. The temperature in 
the mouth and axilla falls rapidly to 95°, 94°, or even 92°; and much 
lower temperatures than these have been recorded. But while the general 
temperature, and especially the surface temperature, thus falls, that in the 
rectum and adjoining parts may stand at 101°, 102°, or even 105°. The 
urinary and biliary secretions are totally suppressed. The patient is wake- 
ful and restless, throwing his arms about, probably complaining much of 
intense thirst and burning at the chest, but withal singularly apathetic. 
When the condition of collapse is fully established, the vomiting and 
diarrhoea either cease completely or greatly diminish, and the patient lies 
ghastly and livid like a corpse, with eyes open and pupils dilated, torpid, 
yet still retaining his senses. During this period the muscular power is 
extremely enfeebled ; yet occasionally the apparently moribund patient 
will rise up in his bed, and even get up and walk across the room. The 
duration of this stage varies from two or three to thirty hours or more, and 
then ends in either death, secondary fever, or convalescence. Death, in 
collapse, sometimes occurs in the course of two or three hours ;, more fre- 
quently it supervenes after the eighth hour — especially between the tenth 
and fourteenth ; but is seldom delayed beyond the twenty-fourth. 

The symptoms which have been above described are not all developed 
in every case of cholera. The muscular cramps are sometimes altogether 
wanting ; while, in some cases, and these perhaps cases of no great severity, 
they are constant and agonizing. Again, vomiting and diarrhoea are not 
invariably present ; and indeed, their absence is almost characteristic of 
some of the most formidable attacks of the disease — those,, namely,, in 
which the patient is suddenly struck clown with symptoms of extreme col- 
lapse, and dies in the course of an hour or two, or less. 

In those patients who survive the period of collapse a gradual change 



228 



SPECIFIC FEBRILE DISEASES. 



of symptoms supervenes. The stage of reaction sets in. This stage is 
said to be often wanting in the cholera of hot climates. In our own 
country, however, it is always present ; but its duration, and the severity 
of its symptoms, depend very largely on the intensity and duration of the 
cold stage which preceded it. It generally comes on between the twelfth 
or fourteenth and the thirtieth hour after invasion. Its first indications 
are slight and vague. A general improvement is visible in the patient ; 
he becomes less restless, his breathing slower and more natural, his pulse 
just perceptible at the wrist ; the lividity of surface slowly disappears ; the 
shrunken tissues expand ; the temperature rises ; perspiration breaks out ; 
and not improbably he falls into a comfortable sleep ; urine begins to be 
secreted ; and the motions are again stained with bile. The temperature, 
however, generally rises somewhat above the normal, and more or less 
obvious febrile disturbance takes place. In some cases the reactionary 
symptoms remain mild and end in convalescence in from twelve to twenty- 
four hours ; but more commonly they undergo aggravation, and may then 
be prolonged (unless cut short by death) to between four and twelve days, 
sometimes longer. The general symptoms have some resemblance to those 
of enteric fever ; the face becomes flushed, the eyes injected, the skin hot 
and sometimes studded with roseolous patches, the pulse increased in 
power and volume and accelerated, the respirations a little more rapid than 
natural, the tongue furred, sometimes dry and brown, and the temperature 
one, two, or three degrees above the normal ; the patient may also present 
more or less delirium, or lie in a torpid or comatose condition. The mo- 
tions, according to Dr. Sutton's observations, often consist on the first 
establishment of reaction of a thin, yellowish fluid, which looks like 
and may be mistaken for urine, and often contain a kind of gelatinous 
substance ; but soon they get green from contained bile, next pea-soup-like, 
and then, consolidating, gradually acquire the normal character. Occa- 
sionally, early in the stage of reaction, the stools contain blood — the 
quantity varying from a mere trace, just sufficient to impart to them a pale- 
pink tinge, up to a flux sufficient to undergo very complete coagulation. 
The stools of the reactive period are often very fetid. The re-establish- 
ment of the urinary secretion is a most important element in the progress 
of the disease. In mild cases it sometimes takes place in twelve hours or 
less ; but it is more common on the second or third day, and may be de- 
layed until the fourth, fifth, or sixth day. The urine first passed is in 
extremely small quantity, and often, during the first twenty-four ' hours, 
remains far below the healthy average. Subsequently the patient may 
pass four, five, or six pints daily. At first it is a little turbid, contains 
traces of albumen, casts of the urinary tubules, and epithelial cells from 
other parts of the urinary passages, but presents a very small amount of 
urea and uric acid, as also of chlorides, phosphates, and sulphates. The 
color varies. Subsequently, while during the progress of fever the urine 
becomes more copious, the amount of urea in it increases, and may even 
exceed the healthy standard. Urocyanogen is sometimes found in the urine. 

The causes of death in the stage of reaction, and the phenomena which 
precede it, present considerable variety. Sometimes cough and difficulty 
<of breathing, with pulmonary engorgement or consolidation, carry the 
patient off. At other times he seems to sink under the continuance of 
intestinal flux, especially when hemorrhage accompanies it ; or symptoms 
much like those of enteritis supervene. In some cases convulsions, coma, 
<or .other cerebral symptoms, which there is good reason to believe are not 



EPIDEMIC CHOLERA. 



229 



unfrequently due immediately to uremic poisoning, precede and apparently 
cause death. Lastly, the patient sometimes sinks from mere asthenia, 
arising directly out of his primary symptoms, or supervening on his typhoid 
condition. 

In the description of cholera above given we have adverted to some of 
the varieties which its attacks present. Especially we have pointed out, 
or incidentally mentioned — that in some cases the patient is struck down 
by the disease, and dies in extreme collapse at the end of perhaps two or 
three hours, without ever having passed an evacuation ; that in a still 
larger number of cases the characteristic vomiting and diarrhoea are pre- 
sent, the stage of collapse gradually supervenes, and the patient dies in 
this stage at the end of from (say) ten to twenty-four hours ; that in many 
cases again, even of considerable severity, the patient emerges from the 
condition of collapse into one of febrile reaction, during which he may 
perish in one of the modes above enumerated, or from which he may glide 
into convalescence ; and, lastly, that in some cases, notwithstanding the 
presence of rice-water stools and other quite characteristic signs of the 
disease, the patient scarcely becomes collapsed at all, and very speedily 
regains health and strength. This enumeration leads up to the important 
questions — as to how far cholera may be so mild as to simulate in its at- 
tacks mere summer or autumnal diarrhoea, and how far also it is possible 
that the latter which (in this country, at all events) concurs with the epi- 
demic prevalence of cholera is influenced by the choleraic poison. As to 
the former question, there can be no doubt, we think — that, just as enteric 
fever, typhus, scarlatina, and other like affections, are sometimes so mild 
and slightly developed as to be (except it may be from associated circum- 
stances) incapable of identification, so cholera may be so mild and so shorn 
of everything characteristic as to be unrecognizable as cholera ; and that 
hence cases of undoubted cholera may simulate, and be taken for, cases of 
ordinary unspecific diarrhoea. As to the latter question, it may be re- 
marked that those who regard cholera as being the outcome of some i epi- 
demic constitution' of the atmosphere, or of some all-pervading miasm, 
might reasonably believe that all morbid conditions tend during the pre- 
valence of cholera to take on a choleraic character. Those, however, 
who believe the choleraic poison to be a form of contagium, and accept 
those views of its operation which we have endeavored to uphold, would 
necessarily discredit its general influence, excepting in the face of over- 
whelming evidence in favor of the existence of such influence. But no 
such evidence, we think, exists. It seems to us, indeed, a fundamental 
and mischievous error to regard the diarrhoea which precedes and accom- 
panies epidemics of cholera as having any other than a fortuitous connec- 
tion with them. 

The mortality of cholera is very great; it varies in different countries 
and in different epidemics, but in round numbers may be estimated on the 
average at about 50 per cent. It is said to be less fatal towards the close 
of an epidemic than at its commencement; and further to be more fatal to 
the very young and very old than to those whose age lies between these 
extremes. 

Any affection attended with sudden and extreme collapse, especially if 
there be at the same time gastro-intestinal disturbance, may be mistaken 
for cholera; among those most liable to be thus confounded are arsenical 
poisoning, and poisoning by croton oil; severe summer cholera; perforation 



230 



SPECIFIC FEBRILE DISEASES. 



of the stomach or bowel; extensive enteritis; and the onset or cold stage 
of severe remittent fever. 

Morbid anatomy and pathology — The post-mortem appearances found 
after death from cholera differ according as death takes place in the stage 
of collapse or in that of reaction. In the former case, the body retains 
much of the shrivelled character and lividity which it presented during 
life, and the dependent parts are often more or less deeply congested. The 
muscles not unfrequently contract for some little time after death, causing 
movements of the limbs; and for the most part rigor mortis is well-marked 
and prolonged. The tissues of the body are preternatu rally dry, the mus- 
cles firm and dark colored, and the systemic veins loaded with blood which 
is manifestly thicker and perhaps darker than normal. For the most part 
the serous cavities are empty of fluid and their surfaces sticky to the feel, 
and they not unfrequently present subserous petechial extravasations. The 
right cavities of the heart are always more or less distended with dark- 
colored, imperfectly coagulated blood. The left ventricle is sometimes 
firmly contracted and empty, sometimes contains a little fluid blood or clot. 
The left auricle also presents a small quantity of blood. The lungs are 
usually much diminished in weight, pale, aniemic, and dryish on section. 
Sometimes, however, they are congested and (edematous below, and they 
may even be more or less congested and oedematous throughout. The 
pulmonary arteries are usually gorged with blood, the veins nearly or quite 
empty. The liver presents no decided departure from health; and the 
gall-bladder is full of bile. The spleen is generally reduced in size. The 
outer surface of the bowels is often injected or of a diffused rosy tint. Their 
mucous membrane is sometimes of a nearly uniform pink tinge, increasing 
in intensity towards the caecum ; or it may present irregular patches of 
congestion, with submucous extravasations; or it may be quite pale. It 
often exhibits a corrugated and sodden appearance; and the solitary and 
Peyer's glands are for the most part enlarged. The contents are an 
opaline or gruel-like fluid, which is sometimes white, sometimes pink from 
admixture with blood. The mucous lining of the stomach is often con- 
gested and mammillated, and the contents generally resemble those of the 
bowels. The kidneys are congested on the venous side, so that the me- 
dullary portions and the superficial veins are injected, while the cortical 
substance remains more or less pale. The urinary bladder is firmly con- 
tracted, and empty or containing a little pus-like fluid. The brain presents 
numerous puncta cruenta. 

If death occurs during reaction, the tissues are found moist; blood occu- 
pies, perhaps in equal degree, both sides of the heart, and not unfrequently 
thick fibrinous coagula are prolonged thence into the aorta ; the lungs are 
congested and oedematous ; and the contents of the intestines present the 
appearance of pea-soup. Besides which changes pneumonia is sometimes 
met with, sometimes distinct inflammation of the intestinal mucous mem- 
brane. 

Other pathological facts of great interest have been ascertained with 
respect to this disease. Although, as has been stated, the blood is inspis- 
sated, it is not by any means so much so as is commonly believed ; but 
(according to Dr. Thudichum) it is more adherent to the bloodvessels than 
natural. The proportion of albumen and salts to its other solid constitu- 
ents is diminished ; and the white corpuscles are often increased relatively 
to the red. The rice-water fluid, as found in the intestines, is alkaline, 
in a state of rapid decomposition, evolves gases (chiefly nitrogen and car- 



EPIDEMIC CHOLERA. 



231 



bonic acid), and contains, besides bacteria, shed epithelium in abundance, 
niucine, albumen, and also butyric acid, acetic acid, ammonia, leucine, and 
inorganic salts. It does not, however, contain urea. There is no doubt 
that after death the mucous surface of the bowels loses its epithelial cover- 
ing, which is thrown off in flakes and suspended in the intestinal contents. 
But it is uncertain whether this is merely a post-mortem change or a. lesion 
occurring during life. It is probably the latter, however, for there appears 
to be a similar tendency to shed the epithelium in almost every other 
part in which epithelium exists, especially in the bladder and urinary 
passages, in the bronchial tubes, and in the ducts of the liver and of the 
salivary glands. Dr. Thudichum's observations show that during the 
period of collapse the blood and the tissues contain very little urea; but 
that its quantity increases during the period of reaction, and soon, if urine 
be not secreted, becomes excessive. 

It remains briefly to discuss the relations between the post-mortem ap- 
pearances and the vital phenomena of the disease. It is obvious that we 
here have an affection which is characterized primarily and mainly by a 
sudden and profound impression on the mucous surface of the alimentary 
canal ; in dependence on which, active destructive changes take place (as 
evidenced by the raised temperature of the parts) and large quantities of 
imperfectly filtered blood, with tendency to rapid decomposition, are poured 
forth with sudden impetuosity. This rapid and profuse discharge tends 
to cause inspissation of the circulating blood, and consequently indirectly, 
but very thoroughly, to drain the tissues of their interstitial fluid, and to 
cause them to shrivel up. Anasarca, indeed, if present becomes thus 
temporarily cured. The absorption of extra- vascular fluid into the blood- 
vessels tends, of course, to maintain the fluidity of the blood ; but, not- 
withstanding this, the blood almost invariably becomes thicker than natural, 
and less easy of transmission through the minuter vessels. On these con- 
ditions follow contraction of all the smaller arteries, excepting, probably, 
those connected with the bowels; general failure of the circulation; arrest 
of normal destructive changes, and therefore of formation of urea; arrest 
of urinary, biliary, and salivary secretions ; and diminution of the normal 
action of the lungs, with cyanosis, lowering of temperature, and generally 
collapse. All the above phenomena flow directly or indirectly from the 
effects of the cholera poison. But how and where does the poison act ? 
Some believe that it acts simply on the intestinal mucous membrane as a 
violent local irritant, just as croton oil or elaterium acts, and that all the 
symptoms which ensue are the result of this irritation of the mucous 
membrance and of the discharge which takes place from it : and there is 
no doubt that symptoms almost identical with those of cholera may be 
produced by the local action of irritants and irritant purgatives. But if 
it be true, as it seems to be, that the foetuses of mothers dying of cholera 
themselves give clear indications of being affected with the disease, it is 
clear that the poison must be diffused throughout the system in addition 
to being contained in the alimentary canal. And, indeed, it is most con- 
sonant with all we know of similar diseases to regard cholera as a systemic 
affection. But whether we are therefore to assume, with Dr. George 
Johnson, that the choleraic virus is contained in the blood ; that by its 
presence there it causes cramp of the voluntary muscles on the one hand, 
and of the capillary arteries of the lungs on the other, so as to prevent 
the passage of blood through them ; that the general collapse, loss of tem- 
perature, and suppression of secretions are due to this mechanical obstruc- 



232 



SPECIFIC FEBRILE DISEASES. 



tion ; and, lastly, that the discharge from the bowels is an effort of nature 
(which should be encouraged) to eliminate the poison from the blood, is 
quite another matter. We confess that, in our view, the intestinal flux is 
not eliminative, but connected, as is the eruption of smallpox, with the local 
growth and multiplication of the poison ; and that there is ample expla- 
nation in the processes which are going on in the bowels of nearly all the 
subsequent phenomena of the disease, including collapse. It is obvious, 
however, that the presence of inspissated blood in the vessels, the drying 
up of the moisture of the tissues, the contraction of the smaller branches 
of the pulmonary artery (assuming it to take place) must all co-operate to 
maintain the patient in the condition of collapse. 

Treatment The value of precautionary and hygienic measures in pre- 
venting or limiting the outbreak of cholera has never been better shown 
than in the history of our own epidemics. Pure water, well filtered, and 
carefully guarded from fecal contamination ; thorough domestic cleanli- 
ness ; and when cholera is present, the immediate disinfection by carbolic 
acid or Condy's fluid of all evacuations, and contaminated articles, are 
conditions of the utmost importance in preventing the spread of the dis- 
ease. 

The medicinal treatment of cholera resolves itself into that of the pro- 
dromal stage, that of the period of collapse, and that of the stage of reac- 
t : on. It is commonly believed that the treatment of the premonitory 
diarrhoea is a matter of vital importance to the patient ; and the assump- 
tion that the diarrhoea, which so often prevails when cholera is epidemic, 
is actually cholera, or simple diarrhoea modified by choleraic influence, has 
led to a general belief in the importance of treating at such times all diar- 
rhceal cases with the object of preventing their development into the graver 
malady. But unfortunately, while the majority of physicians laud astrin- 
gents for this purpose, others prefer castor oil, and all refer to statistics in 
proof of the efficacy of their respective modes of treatment. We have 
asserted our own belief that if a case be one of simple diarrhoea, it will not 
run on to cholera under any form of treatment ; and we may add that, if 
the case be one of commencing cholera, there is no more ground for be- 
lieving that it can be cut short than for believing that typhoid fever or 
hooping cough can be cut short. We do not believe that either castor oil 
or astringents have any such influence. 

In the period of collapse all sorts of remedies have been adopted ; some 
have given calomel in large doses, some opium, some brandy, some castor- 
oil; but it seems clear that drugs administered by the mouth must in such 
cases prove quite inoperative. And this is certainly the opinion of nearly 
all except the enthusiastic supporters of some special drug. During this 
stage the patient should be kept in the horizontal position ; he should be 
allowed cold or ice-cold w r ater to relieve his insatiable drought ; and his 
surface should be kept warm by the application of hot bottles or flannels, 
or by friction. The placing of the patient in a bath, two or three degrees 
above blood heat, is often very comforting and apparently of much service. 
The vapor bath is equally beneficial. It is in this stage that the injection 
of saline fluids into the veins has been so frequently tried, and occasionally 
w r ith success. The immediate effect of injection is often marvellous, the 
moribund patient regains his healthy appearance, his respirations, pulse, 
and voice resume their normal characters, and he sits up in bed conversing 
cheerfully. But the improvement is generally of short duration ; he falls 
again into collapse, and probably dies. The solution employed should 



HYDROPHOBIA. 



233 



resemble as nearly as possible the serum of the blood, and should be in- 
jected slowly and cautiously, in quantities varying, according to its effects, 
between 10 oz. and one or two pints. Schmidt recommends the following: 
chloride of sodium 60 parts, chloride of potassium 6, phosphate of soda 3, 
carbonate of soda 20 ; of which mixture 140 grains are to be dissolved in 
40 oz. of distilled water, and filtered. The temperature of the fluid as it 
enters the veins should be a little over that of the blood. Cramp may be 
relieved by friction, or the inhalation of chloroform. 

Great care must be taken of the patient during the reactionary stage. 
He should be kept cool. Diarrhoea, and vomiting must be restrained — the 
former by astringents, such as Dover's powder, compound kino powder, 
or the aromatic powder of chalk and opium ; the latter by lime-water, bis- 
muth, and the like, or the use of ice, or the application of counter-irritants. 
The food should be fluid, nutritious, and unstimulating ; milk, broth, 
arrowroot, sago, barley-water, and eggs are the most appropriate. It is 
questionable whether stimulants are beneficial. If given they should be 
in small doses much diluted. Tt is of essential importance that the urinary 
secretion be restored; but it is unwise to employ stimulant diuretics for 
the purpose. Saline effervescents may relieve sickness, and at the same 
time promote urine. Cupping-glasses and counter-irritation to the lumbar 
region are believed to be sometimes serviceable. If dysenteric or enteritic 
symptoms come on, opium must be freely used. 



XX. HYDROPHOBIA. {Rabies.) 

Definition — A disease special to dogs, wolves, foxes, and animals 
closely related to them, among which it spreads by direct contagion, and 
from which it is imparted (but by inoculation only) to other animals and 
to human beings. Its most characteristic features in man are the spasms 
and terror which are induced by the attempt to swallow fluids, or even 
by the thought of sw alio wing, and its invariably and rapidly fatal issue. 

Causation and history — There is no evidence to show that this disease 
ever arises spontaneously among dogs anymore than smallpox does among 
men ; and further, there is reason to believe that it spreads among them 
by inoculation only, or rather, perhaps, by the introduction of the saliva 
of diseased animals into the tissues of those which are healthy, by what- 
ever process that introduction is effected. The cause of the disease is evi- 
dently a specific virus which resides mainly in the viscid secretions which 
are furnished by the mucous membrane of the mouth and fauces and by 
the salivary glands. The prevalence of rabies, like that of other infectious 
diseases, varies very greatly at different periods ; sometimes it is scarcely 
observed for many years together, at other times it prevails widely in an 
epidemic form. The circumstances on which these differences depend are 
obscure ; for climate, season, dearth of water and of food, and other such 
conditions do not seem to have any influence over it. It is important, 
however, to knowthat the virus never inoculates when it is applied to the 
surface of the sound skin ; and that only a small proportion of those who 
are bitten by rabid dogs become hydrophobic. This proportion has been 
variously estimated at from 5 to 50 per cent. One main reason, doubtless, 
of the immunity which so many who are bitten enjoy, is the fact that they 



234 



SPECIFIC FEBRILE DISEASES. 



are wounded through their clothes, and that the fangs are thus cleansed 
from all moisture before they enter the skin. 

Symptoms and progress. — After a man has been inoculated with the 
saliva of an animal suffering from rabies, the wound in most cases heals 
as readily and quickly as a wound not so inoculated would heal ; at all 
events, there is nothing in its progress to indicate the existence of anything 
unusual. A period of latency follows, which is generally remarkable for 
its long duration. In most cases the first symptoms show themselves be- 
tween the fourth and eighth week, but they have appeared in the course of 
a few days, and have been delayed for months and even it is asserted for 
several years. They rarely, however, appear after four months. The out- 
break of hydrophobia is in some cases preceded for a day or two by heat, 
tingling or pain at the part on which the injury was inflicted, the pain 
being sometimes intense and extending upwards in the course of the sen- 
sory nerves. There is occasionally also renewed inflammation and suppu- 
ration or ulceration. In many cases, on the other hand, no such pheno- 
mena present themselves. 

The period of invasion, which is sometimes termed the 4 melancholic 
stage,' is attended with a variety of symptoms, most of which have no 
particular significance, and which gradually merge in those of the fully- 
developed disease. The patient complains of feverishness and shivering, 
with dryness of mouth and thirst, want of sleep, epigastric uneasiness and 
indefinable anxiety. He is pale, anxious, but distraught in his aspect, 
with restless eyes and dilated pupils, restless and fidgety in his movements, 
garrulous, but speaking in short sentences and in a jerky, abrupt manner. 
He suffers also from increased frequency of the heart's action and loss of 
appetite, perhaps nausea and vomiting ; and not improbably has even now 
some feeling of constriction about the fauces with a disinclination to swal- 
low fluids, quickened and sighing respiration, general hyperesthesia, and 
a tendency to priapism and seminal discharges. 

At the end of two or three days the next stage has become fully developed. 
This is sometimes termed the 4 stage of excitement,' and in it the disease 
assumes all its typical features. The strange agitation of the patient has 
become more marked ; his eyes are bright, mobile, wild, and glance with 
suspicion or terror about him ; his hair is rough, his skin pale, his brow 
contracted, his aspect indeed closely resembles that of a patient with acute 
mania ; he is still inclined to be talkative, frequently making odd but per- 
tinent remarks; he is probably quite sensible, and capable of understanding 
and reasoning ; at the same time he is obviously under the domination of 
some indefinable but great horror ; and occasionally perhaps he has hallu- 
cinations, and is liable to outbreaks of violent maniacal excitement in 
which he may endeavor to injure himself or others. The thirst lias in- 
creased ; his mouth and fauces are congested and dry ; and a quantity of 
tenacious saliva accumulates, which he is constantly hawking up and spit- 
ting about him with a noise which has often been taken for a bark. But, 
above all, the disinclination to swallow fluids has now become an almost 
perfect inability to swallow them, and a dread of making the attempt. 
He will still perhaps resolutely try to drink, will take the glass of water 
in his hand, prepare himself with strange calm and deliberation to make 
one supreme effort, put the vessel hurriedly to his lips, make a sudden 
gulp, and then, with or without swallowing a little of it, eject the bulk 
of it spasmodically and violently from his mouth, and throw the glass 
away. A convulsive attack has been induced, marked by general tremors 



HYDROPHOBIA. 



235 



or shuddering, and violent spasmodic action of the muscles of deglutition 
and respiration, which lasts for a few seconds, and leaves the patient for a 
minute or two in a state of painful agitation. The fear of the recurrence 
of these terrible convulsions is constantly before him, and their actual recur- 
rence is soon induced, not merely by the attempt to swallow, but even by 
the sight or sound or thought of fluid. The general hyperesthesia, which 
has already been adverted to, becomes more acute. The patient will often 
complain of the mere weight of the hand, or of his bed-clothes ; and a 
draught of cold air upon the surface suffices to induce a convulsive attack. 
Bright objects, and loud or harsh or unaccustomed sounds are painful to 
him, excite a feeling of terror, and not unfrequently also provoke convul- 
sions. The sexual excitement, of which the patient complains bitterly, 
may also continue. He passes urine frequently. 

As the disease progresses all the symptoms become more severe ; the 
patient gets feebler, his pulse quick, irregular, and small, his skin clammy, 
his voice hoarse; the tenacious mucus which is secreted by the mouth and 
fauces accumulates and becomes more difficult of expulsion ; the paroxysms 
of general convulsive action and of spasm of the respiratory muscles in- 
crease in severity and frequency ; and at length he dies either of sudden 
asphyxia in one of these convulsive attacks, or of slow asphyxia induced 
by their rapid recurrence, or of exhaustion, aided possibly by a general 
paralytic condition. 

The most remarkable phenomena of the disease are, first, the hyper- 
esthesia of the skin and organs of sense ; second, the tendency which 
impressions on these organs, and attempts to swallow, or thoughts of 
swallowing liquids, have in producing clonic and tonic spasms of the respi- 
ratory muscles; and, third, the wakefulness, horror, and tendency to yield 
(while apparently still quite rational) to insane impulses. The last condi- 
tion is occasionally absent; or the patient only rambles slightly immediately 
before death. The disease is invariably fatal, and generally terminates 
between the second and fourth day. 

Rabies in dogs presents in great measure the same symptoms as hydro- 
phobia in man. There are, however, one or two important points of dis- 
tinction : — namely, dogs are not afraid of water, and will indeed, on the 
contrary, bury their muzzles jn water while at the height of the disease; 
cutaneous hyperesthesia seems to be absent in them ; and towards the 
close a paralytic condition supervenes, involving especially their hinder 
extremities and the lower jaw. 

Morbid anatomy has not as yet thrown any important light upon the 
phenomena of hydrophobia. The muscles retain their rigidity for some 
time after death, and there is more or less obvious congestion of the pos- 
terior surface of the corpse, and of the fauces, pharynx, oesophagus, larynx, 
trachea, and lungs. Recent investigations 1 by Drs. Coats, Gowers, Green- 
field, and others have demonstrated the presence of hyperemia of the cen- 
tral nervous organs, with the accumulation of leucocytes around the smaller 
vessels and capillaries of the cerebral convolutions, the ganglia at the base 
of the brain, the gray matter of the cord, and especially that of the me- 
dulla oblongata. Small extravasations of blood have also been found in the 
gray matter of the dorsal and cervical regions of the cord. Dr. Coates 
further describes extravasation of leucocytes into the salivary glands, mu- 
cous glands of the larynx, and kidneys. There can be but little doubt that 



1 Lancet, vol. ii. 1877, p. 882. 



236 



SPECIFIC FEBRILE DISEASES. 



the hydrophobic virus exerts its influence mainly on the sensory and emo- 
tional regions of the central nervous organs. Dr. Marochetti, in 1820, 
described the formation of small vesicles beneath the tongue in persons 
bitten by mad dogs. These vesicles which have also been described sub- 
sequently by one or two other physicians, are said only to occur during the 
second week after inoculation. 

Treatment. — Whenever a patient has been bitten by a rabid animal or 
one suspected of having rabies, the wounded part should at once be excised 
and the remaining raw surface freely treated with caustic potash, nitric acid, 
the acid nitrate of mercury, the actual cautery, or some equally efficient, 
destructive agent. No remedy has been discovered competent to arrest the 
progress of the once established disease. Drugs producing narcotism and 
anaesthesia might seem to offer some chance of benefit, but it is doubtful if 
any has been found of service, except perhaps in the relief of suffering. It 
should be observed, however, that a case of recovery is said to have occurred 
in 1874, in the practice of Dr. Offenburg, of Winkrath, under the use of 
injections of curara, of which about a third of a grain was administered 
every fifteen minutes or so. The patient was well on the eighth day. Any 
drug that may be employed should be administered by inhalation, by the 
rectum, or by subcutaneous injection. Tracheotomy has been suggested 
in the hope of averting death by asphyxia. Great care should be taken 
to prevent the patient from doing violence either to himself or to those 
about him, and especially to prevent inoculation of wounds by the saliva 
which lie disperses. 



XXI. GLANDERS. FARCY. (Equinia.) 

Definition A specific disease, special to the horse and animals of the 

same genus, but communicable to man, and characterized by a peculiar 
tubercular affection of the nasal and respiratory mucous membranes and of 
the skin, lungs, lymphatic glands and other parts of the body. 

Causation and history Whether or not the disease originates sponta- 
neously in the horse is a matter of dispute. It is certain, however, that it 
spreads readily among horses and from them to men by contagion — mainly 
by the virus contained in the secretions of the nasal mucous membrane ; 
and, further, that it is similarly transmissible from man to man. 

Symptoms and progress — The period of incubation probably varies 
between one and about fifteen days. It is said to be occasionally much 
prolonged. Two varieties of equinia are met with, which go by the re- 
spective names of 'glanders' and '•farcy? the difference between them 
depending mainly on the seat of inoculation, and on the absence or presence 
of early affection of the nose and air-passages. These varieties run into 
one another even in the horse ; in man they are generally combined. The 
symptoms of invasion are those of intense febrile disturbance — heat of 
skin, rigors, acceleration of pulse, headache, febrile urine, pains in muscles 
and joints, and often nausea and vomiting, and profuse perspirations. The 
specific phenomena of the disease soon follow. These consist in an affec- 
tion of the nasal mucous membrane and of the mucous surfaces which are 
continuous with it, and an eruption on the skin. The mucous surface of 
the nostrils becomes congested, and secretes a thin, acrid, watery fluid, 
which soon gets thick, tenacious and profuse, and probably assumes at 



GLANDERS. FARCY. 



231 



length the characters of sanious pus. The cutaneous eruption is thinly 
and irregularly scattered, and chiefly on the face, extremities, neck, and 
abdomen. It consists at first of red points ; but these soon increase in 
size, ultimately perhaps attaining the bulk of peas, and feeling hard and 
shotty between the fingers, and not unlike syphilitic chancres. A vesicle 
or pustule soon makes its appearance on the summit of each spot, enlarges, 
bursts, exudes a more or less abundant purulent fluid, and leaves an irreg- 
ular sloughy ulcer, with a livid margin. A little later, other phenomena 
manifest themselves; the conjunctivae yield a purulent secretion; sores 
arise on various parts of the mucous surface of the oral cavity and pharynx; 
and bronchitic, pulmonic or pleuritic symptoms are added ; erysipelatous 
redness and swelling of the eyelids, nose, cheeks and forehead become de- 
veloped ; and subcutaneous or deeper-seated tubercles and abscesses — the 
latter often of considerable size — appear in various parts, but mainly in the 
face and in the vicinity of joints. Whilst these symptoms are in progress, 
the patient becomes weak and prostrate, his pulse quick and feeble, his 
muscles tremulous, his tongue dry and brown, and delirium comes on ; in 
a word, typhoid symptoms rapidly develop themselves, on which coma 
supervenes, and death soon follows. The breath during this period is 
generally very fetid, the perspiration abundant, there is often diarrhoea, 
and gangrene sometimes attacks the nose, eyelids, and other parts. The 
course of the disease is generally acute ; the- temperature may rise to 104° 
or even to 106°; and death supervenes, sometimes during the first few 
days, but more commonly between the seventh and fifteenth or sixteenth. 
Occasionally in man (but much more commonly in the horse) the disease 
is chronic. The invasion is then more gradual, the various phenomena 
follow one another at longer intervals and the eruption is often absent; 
but the subcutaneous abscesses which form become larger, the resulting 
ulcers are often attended with sloughing, and the affection of the nostrils 
extends and leads even to the exposure and destruction of the bones. The 
patient passes into a hectic condition, and may linger for weeks, months, 
or years. The blood is said by Colin to be greatly surcharged with white 
corpuscles. 

Farcy is generally dependent on the inoculation of a wound on some 
part of the trunk or limbs. The inoculated part gets inflamed and painful, 
and the absorbent vessels and glands in relation with it soon become 
similarly affected. Then supervene more or less of the febrile disturbance 
that characterizes glanders, and the formation of subcutaneous lumps 
(farcy-buts) and abscesses ; frequently, too, the absorbent glands become 
generally inflamed and suppurate. The cutaneous rash is not so frequently 
present in farcy as in glanders, and the nasal inflammation is often absent. 
It must be added, however, that all the special symptoms of glanders oc- 
casionally supervene. This variety of equinia may occur in either the 
acute or the chronic form. The latter is sometimes exceedingly ill-marked 
and difficult of diagnosis. 

Equinia is generally a fatal disease. The chronic forms are most likely 
to be followed by recovery, and farcy more so than glanders. In its early 
stage, and in the absence of rash or nasal implication, equinia may be 
readily mistaken for acute rheumatism or pyaemia. 

Morbid anatomy — The anatomical phenomena of equinia consist mainly 
in the formation of tubercles, presenting to a great extent the structural 
features of true tubercles, and like these tending rapidly to undergo caseous 
degeneration and liquefaction or suppuration. When superficial, they 



238 



SPECIFIC FEBRILE DISEASES. 



speedily form unhealthy-looking ulcers. When deeper seated they become 
converted into abscesses, which then gradually enlarge and ultimately 
burst. The tubercles vary from the size perhaps of a pin's head to that of 
a pea or bean. It is to their development in connection with the mucous 
membrane of the nose that the peculiar symptoms referable to this organ 
are due. They also form in the mouth and fauces, in the larynx, trachea, 
and bronchial tubes ; and they appear in the substance of the lungs, pro- 
ducing a condition not unlike that of ordinary lobular pneumonia, and 
often inducing pleural inflammation. The cutaneous eruption is due to 
the growth of these tubercles in the skin ; and the subcutaneous lumps and 
abscesses, and those which arise in the substance of muscles, are of the 
same nature. The kidneys, spleen, testicles, and other organs are also 
occasionally affected. Implication of the lymphatic glands is not unfre- 
quent, but must be regarded as generally, if not always, secondary to 
specific lesions Occurring in parts with which they are connected. More 
or less of simple inflammation is generally associated with the specific 
lesions. 

Treatment It is impossible to lay down any authoritative rules for the 

treatment of equinia. No specific is known, and no drug which has any 
favorable influence over its course. Iodine, arsenic, and strychnia have 
each been recommended. All that can be done, probably, is to support 
the patient by nourishment, stimulants, and tonics ; to relieve pain and 
other symptoms ; and to cleanse, and treat with stimulating or astringent 
lotions, or other applications, the nasal mucous membrane and other in- 
flamed and ulcerated parts which are within reach. During convales- 
cence change of air and good diet are of course important. 



XXII. SYPHILIS. 

Definition A specific disorder, communicable only by inoculation, 

resembling the exanthemata in the facts, that it presents a period of la- 
tency, and a period during which characteristic eruptions make their appear- 
ance, and that one attack confers protection ; but differing from them in 
the remarkably long duration of these periods, and in the tendency to the 
recurrence, it may be for many years, of specific lesions. 

Causation and history. — Syphilis has occasionally prevailed in the form 
of widespread and severe epidemics. One such epidemic passed through 
Europe during the latter part of the fifteenth century ; and it was probably 
in great measure owing to this fact that, for a time, it came to be assumed 
that the disease first made its appearance in Europe after the discovery of 
America, and had been imported from that continent. There is no doubt, 
however, that this was an erroneous assumption ; and that, just as syphilis 
prevails now, so it has prevailed from the earliest times both in Europe 
and in the other quarters of the Old World. Like many other diseases, 
syphilis w r as long confounded with affections which, though often asso- 
ciated with it or arising under analogous circumstances, aie essentially 
distinct from it. Hunter regarded gonorrhoea as one of its manifestations, 
and even until quite recently other forms of circumscribed inflammation of 
the surface of the genital organs have been confused with the true chancre 
— the sore which arises at the point of syphilitic inoculation. But, thanks 



SYPHILIS. 



239 



to the labors of Ricord and other recent observers, including Mr. Henry 
Lee, the phenomena of syphilis apparently have now been fully disen- 
tangled from those of the maladies which simulate it, and our knowledge 
of syphilis is as accurate as is our knowledge of scarlet fever or of small- 
pox. The symptoms of syphilis are quite characteristic, and when fully 
developed, can rarely escape ready recognition ; yet the disease, though 
maintaining its identity and typical features, has varied very greatly in 
its virulence at different times and in different countries, under circum- 
stances the nature and relative importance of which it is not easy to esti- 
mate. Of the specific nature of syphilis, therefore, there can be no doubt. 
There is equally no doubt that it spreads by means of a specific contagium, 
and that there is no evidence to show that it ever originates spontaneously. 
The specific poison of syphilis is never imparted, like that of typhus, by 
atmospheric conveyance, or, like that of cholera, by means of diffusion 
through water; it acts only when directly introduced by inoculation. For 
the most part it is imparted in the act of sexual intercourse by the secre- 
tions which are furnished by primary or secondary sores — the thin cuticular 
covering of the glans penis and inner surface of the prepuce, and the mucous 
membrane of the urethra, and the corresponding parts in the female, be- 
coming readily inoculated even when no breach of surface exists. It is 
also not unfrequently transmitted from the sucking child to its nurse, or 
from the nurse to her suckling, either from the mucous membrane of the 
mouth to the nipple, or conversely, or from mouth to mouth. But, indeed, 
inoculation may take place at any part, provided only the cuticular layer 
be not too thick, or there be an excoriation or wound ; thus syphilis has 
not unfrequently been accidentally inoculated on the hands of medical men, 
and occasionally has been imparted by the operation of vaccination. And, 
lastly, it is a common thing for syphilitic parents to procreate children who 
also are syphilitic. Thus a syphilitic mother may have a syphilitic child, 
the father remaining uncontaminated ; or a syphilitic father may beget a 
syphilitic child, and may infect the mother either directly, or indirectly 
through the foetus. The contagium of syphilis resides in its most virulent 
form, doubtless, in the primary syphilitic sores, and in the indurated glands 
which succeed to them; but the contagious influence persists during the 
secondary phenomena of the disease, and also during the period of so-called 
'tertiary' manifestations, as is distinctly proved by the fact already ad- 
verted to — namely, the transmission of the disease in its later stages from 
parents to their offspring and from these to healthy wet-nurses. Experi- 
ments have been made which seem to prove that the blood of syphilitic 
patients possesses contagious properties ; but there can be no doubt that, 
as well in the later as. in the earlier stages of the disease, the virus is 
mainly concentrated in the specific lesions. It may be added that the 
secretions of syphilitic patients, more especially the milk, semen, and pro- 
ducts of the mucous surfaces, have been supposed to possess infectious 
properties. But Mr. H. Lee is probably right when he insists that only 
those organs yield infectious discharges which are either distinctly impli- 
cated in the syphilitic process or are in a condition of inflammation. The 
protective influence of one attack of syphilis has only been fully recognized 
since the true disease has been disencumbered of the maladies which had 
grouped themselves with it. It is now established beyond doubt that 
syphilitic inoculation affords as secure a protection against subsequent 
attempts at inoculation as does one attack of smallpox or scarlet fever 
against subsequent attacks of either of these affections ; that a person fully 



240 



SPECIFIC FEBRILE DISEASES. 



under the influence of the syphilitic poison, or who has had an attack from 
which he has recovered, very rarely acquires a chancre even when inocu- 
lated under the most advantageous circumstances, and even more rarely 
suffers in consequence from the secondary symptoms which so surely follow 
on the primary inoculation ; and, further, that a person inoculated a second 
time, during the period which elapses between a primary inoculation and 
the maturation of the primary chancre, has as the result of his second in- 
oculation a modified chancre — a chancre which runs its course with excep- 
tional rapidity, and attains its full development concurrently with its elder 
brother. 

Symptoms and progress — 1. Primary symptoms. When a successful 
inoculation has been effected on an unprotected person, the virus remains 
apparently quiescent for a period of uncertain duration, but which is esti- 
mated by Lancereaux at from eighteeen to thirty-five days, with a mean of 
twenty-eight days. At the end of that time, a minute dusky red papule 
makes its appearance, which for the most part is unattended with either 
pain or itching, and slowly enlarges. Soon a thin grayish crust, the result 
of superficial necrosis, forms on its most prominent part. Whilst the 
papule gradually increases in area, successive crusts are formed and shed 
from its surface, which thus becomes more and more eroded ; so that be- 
fore long the papule, which has now become a tubercle, displays an elevated 
dusky red margin surrounding a concave excavation, with a gray dry 
surface. Almost from the beginning the papule has a remarkable indurated 
character and appears imbedded, as it were, in the substance of the. skin. 
These characters it retains, the induration extending a little beyond the 
area of elevation, and presenting a very obvious edge, so that the mass 
can be readily grasped between the finger and thumb. At the end of 
about six weeks the tubercle has attained its complete development, and 
is perhaps of the size of half a pea, or somewhat larger. It then begins 
slowly to subside, and after a while cicatrizes, generally, however, leaving 
behind more or less dusky discoloration, induration, and permanent depres- 
sion. This is the course of the true Hunterian chancre. But, just as the 
inoculated cow-pox vesicle presents many deviations from its natural course, 
so does the pimple which results from syphilitic inoculation. For a de- 
scription of these reference must be made to surgical works. It should be 
stated, however, that inoculation sometimes takes place without the devel- 
opment of any appreciable local sore, and that a sore may have existed 
and yet no visible cicatrix remain. 

A week or two, usually, after the first appearance of the chancre, the 
lymphatic glands in relation with the affected part begin to enlarge. If, 
therefore, the chancre be on the genital organs the glands of one or both 
groins suffer. The enlargement is slow and painless. For the most part 
several glands are affected, and each probably attains the size of an almond 
shell. They remain freely movable under the integuments, and are char- 
acterized, like the chancre itself, by extreme induration. They seldom 
undergo suppuration, but remain with little change for months or years. 

The period, to which the above phenomena belong, corresponds exactly 
to the incubation of the exanthemata, and consequently to that period in 
the inoculated small-pox during which the primary pustule attains matu- 
rity, and which precedes the general variolous outbreak. 

2. Secondary symptoms — From six weeks to three months, generally 
perhaps between sixty and seventy days, after inoculation, the eruptive 
stage, or stage of secondary symptoms, supervenes. The invasion of this 



SYPHILIS. 



241 



stage is often indicated by slight febrile symptoms, attended with more or 
less obvious recurring exacerbations, increased frequency of pulse, loss of 
appetite, weakness and emaciation, cachexia, restlessness, want of sleep, 
and pains more or less variable but augmenting towards night in the head, 
joints, and back. Shortly afterwards, or sometimes concurrently with the 
febrile disturbance, phenomena of a more characteristic kind manifest 
themselves. Among the earliest of these are certain affections of the skin 
and mucous membranes, and inflammations of the joints, bones, and eyes. 
The cutaneous affection, which is a form of roseola, generally first appears 
on the trunk, but before long involves the face and extremities, including 
the palms and soles. It is in the beginning a mere subcutaneous rash of 
roundish dusky-red spots, varying from one to two or three lines in diam- 
eter, and fading at the edges. But they soon become slightly elevated and 
lenticular in form. They are variously scattered, but are not unfrequently 
grouped in segments of circles or in circles. The rash comes out in suc- 
cessive crops, and may continue off and on for some two or three months. 
In association with it the hair not unfrequently gets dry and loses its gloss, 
and presently begins to fall out ; and thus more or less complete baldness 
is apt to ensue. This roseola is sometimes the only rash which makes its 
appearance, but very commonly it constitutes the first stage of some other 
variety of skin-disease. Thus, sometimes the individual roseolous spots 
or the patches formed by the coalescence of several, gradually enlarge, and 
fading away in the centre form circles or irregularly rounded marginated 
tracts of erythema circinatum ; sometimes as they enlarge they get covered 
with thin scales, and acquire a close resemblance to lepra or psoriasis ; 
sometimes they assume the form of distinct but flat tubercles ; sometimes 
they become the seat of vesicles or blebs, and occasionally even of pustules. 
And hence the secondary eruption may acquire an erythematous, scaly, 
papular or tubercular, vesicular or pustular condition, or may present 
several or all of these characters at the same time variously combined. 
But besides this peculiar polymorphous character, wiiich of itself points to 
syphilis, there are generally certain peculiarities about the eruption which, 
apart from all other considerations, indicate its specific character. In the 
first place, it often presents a peculiar dusky-red or coppery tint, which is 
due to some pigmentary deposit in the substance of the cutis, and tends to 
persist long after the actual eruption has disappeared. It may be worth 
while to remark that occasionally the course of the superficial veins in the 
extremities, and especially along the shins, becomes mapped out by similar 
dusky pigmentary stains. This condition is not peculiar, however, to 
syphilis. In the second place, syphilitic eruptions have a singular aptitude 
to affect those parts which the non-specific eruptions they resemble specially 
avoid; they are common on the flexor aspects of the joints, about the fore- 
head, wdiere they often cause the so-called 'corona veneris,' and especially 
in the palms and soles. It may be added that, in syphilitic lepra, the 
formation of scales is usually much more scanty than in the non-specinV 
variety of the disease ; that it is almost impossible to make any real dis- 
tinction between the several syphilitic affections of the palms and soles, 
inasmuch as all are generally attended with desquamation ; and that scabs, 
due apparently to the interstitial effusion of serum or pus, sometimes form- 
on leprous or tubercular patches, which thus pass by easy gradations into 
the truly vesicular and pustular conditions. 

The morbid processes of the mucous membranes first show themselves in.; 
the fauces and pharynx, generally upon the tonsils. On the last, which 
then present an inflammatory blush, shallow ulcers, for the most part reni- 
16 



242 



SPECIFIC FEBRILE DISEASES. 



form in shape, make their appearance; they are generally unattended with 
pain or even uneasiness, and disappear after a few weeks. Similar sores 
are also apt to form on the palate and internal surface of the cheeks, on 
the tongue and lips. In addition, condylomata or mucous tubercles often 
become developed in the mouth, fauces, and pharynx, about the anus, upon 
the mucous or delicate cuticular surface of the genital organs, and in those 
parts of the skin which are in constant apposition and consequently always 
moist. Mucous tubercles are roundish, oval, or more or less irregular con- 
gested tabular elevations, not fibrous, warty, or villous, but uniform in 
texture and soft, with a tendency to be covered with a grayish or yellowish 
film, to exude abundant moisture, to secrete pus, or to undergo ulceration. 
Similar formations may arise in the rectum, oesophagus, nose, larynx, 
trachea, and bronchial tubes, and not improbably in other parts of the 
mucous tracts. 

The pains in the joints and bones are of a rheumatic character, and are 
apt to become especially severe at night. There may be no visible change 
in the parts affected ; sometimes, however, there is more or less obvious 
periostitis, or arthritis and effusion into the joints. True nodes are com- 
paratively seldom developed at this time. 

The alfec.ions of the eyes are twofold. The most obvious is a form of iritis, 
attended with little pain, uneasiness, or intolerance of light, but with more 
or less of the ordinary form of sclerotic injection which accompanies iritis. 
Exudation of rust-colored lymph occurs at the surface of the iris, mainly, 
however, at its inner margin, and though much less frequently at its outer 
margin. In the former situation the lymph may form a uniform tumid 
ring, and in either situation a series of reddish beads. At the same time 
the iris becomes sluggish or immovable, and probably adheres to the sur- 
face of the lens, and the aqueous humor gets turbid and yellowish from 
admixture with inflammatory products. The less obvious but more serious 
form is retinitis, coming on insidiously without external congestion, pain, 
or intolerance of light, but marked by increasing haziness of vision and 
indications of retinal congestion and extravasation. 

3. Tertiary symptoms. — The period of secondary symptoms, after lasting 
for a few weeks or months, for the most part terminates in spontaneous 
convalescence ; and the patient may possibly remain henceforward free 
from disease. But more commonly, after the lapse of an uncertain period, 
generally from six months to two years, but sometimes twenty years or 
more, other characteristic lesions manifest themselves, distinctly referrible 
to the syphilitic poison, and usually termed tertiary symptoms. It must, 
however, be added that, although there is generally a distinct interval 
between the subsidence of the secondary and the onset of the tertiary 
symptoms, they do occasionally, and perhaps not unfrequently, become 
intermingled, or pass without break one into the other. The chief char- 
acters by which tertiary symptoms are distinguishable from those of earlier 
occurrence are, first, their dependence, for the most part, on a specific 
overgrowth of tissue — the formation of gummata ; second, their great 
inveteracy and tendency to recur ; third, their involvement of internal 
organs as well as of parts that are superficial ; and fourth, their want of 
symmetry. We will consider the more important of these lesions seriatim, 
and in reference to the organs which they affect. 

a. Skin — The most common form of skin disease is characterized by 
the appearance of dusky red or coppery flat tubercles, which differ little if 
at all, in the first instance, from those which have been described among 



SYPHILIS. 



243 



the secondary symptoms ; they are, however, generally larger, more promi- 
nent and more indurated, and occur sometimes widely scattered, sometimes 
collected into irregular groups, sometimes arranged in the form of cres- 
cents, circles, or sinuous lines. In the first case they gradually increase 
in number, and coalesce ; in the second, the groups tend to grow in area, 
and not unfrequently also in thickness, so as to form irregular tuberculated 
elevations of considerable extent and thickness ; in the last case the affec- 
tion tends to spread centrifugally, slowly invading the healthy surface by 
a line of ever new tubercles, while the parts primarily affected return to a 
state of comparative health. In some instances the tubercles become scaly 
on the surface, the affection presenting a certain amount of resemblance to 
some forms of lepra ; in other instances they undergo superficial molecular 
necrosis, they get more or less deeply eroded, and a scab forms without a 
vesicle or pustule having ever been developed ; in other cases each papule 
undergoes suppuration, and a thick adherent ecthymatous scab results; and, 
lastly, ulceration is not unfrequent. But whichever of these processes 
takes place, the disappearance of the active lesion is always followed by 
the formation of indelible depressed cicatrices ; and the progress of the 
serpiginous form can always be traced by the cicatricial surface which it 
leaves in its wake, and the pre-existence of large patches always recog- 
nized by the persistence of a corresponding cicatrix. The tubercular 
eruptions here described, although essentially identical with one another, 
are often denominated, according as one or other peculiarity predominates, 
tubercular, pustular, or serpiginous syphilide, or syphilitic lupus, or psori- 
asis. They affect almost any part of the body, but are perhaps especially 
common on the face, neck and shoulders, buttocks and extremities. When 
they occur, as they frequently do, on the palms and soles, there is little to 
distinguish them from secondary lepra. Another well-marked form of 
skin-affection is that known by the name of syphilitic rupia. It consists 
in the scanty formation, indiscriminately on various parts of the body, of 
isolated blebs, each of which arises on a congested indurated base, and 
may attain the diameter of a fourpennypiece. Their contents are clear 
and limpid, or turbid and sanious, and soon concrete into scabs, each of 
which, from constant additions to its edges and base, rapidly attains large 
dimensions — a thickness, for example, varying from a quarter to three- 
quarters of an inch, and a form which may resemble that of a limpet-shell 
or oyster-shell, or may be merely irregular and rocky. The base at the 
same time becomes deeply excavated; and on removing the scab a deep 
unhealthy slowly healing ulcer is revealed. These rupial sores leave re- 
markably deep cicatrices. 

Very frequently, altogether independently of any primary cutaneous 
disorder, hard nodules, from the size of a pea to that of a filbert, appear 
singly or in groups in the substance of the subcutaneous connective tissue. 
They are unattended with pain, and very slow in their progress; but after 
a while they adhere to the skin, which then becomes somewhat prominent 
over them, assumes a dusky red tint, and gives to the finger a sensation of 
elasticity and resistance, or ' bogginess.' Before long the central portion 
of the involved skin becomes perforated in one or more points, and a viscid, 
turbid, or sanious fluid escapes, together with shreds or a mass of subcuta- 
neous slough. In this way a deep cavity results, the boundaries of which 
are formed of ragged grayish or yellowish tissue. If groups of such 
masses soften, we get a number of such cavities side by side, the skin 
appears irregularly honeycombed, and the bridles which intervene between 



244 



SPECIFIC FEBRILE DISEASES. 



the adjoining openings get undermined by the coalescence beneath them 
of the contiguous cavities. Thus extensive and deep destruction of skin 
and subcutaneous connective tissue takes place, which is very slow of 
repair, and followed by deep cicatrices. 

b. Mucous membranes. — The affections of the mucous surfaces have 
much resemblance to those of the skin. They are chiefly superficial and 
tubercular, or submucous and gummatous. The former are especially fre- 
quent on the tonsils, fauces, soft palate, pharynx, tongue, and other parts 
of the mucous surface of the oral cavity, and in the larynx ; are followed 
by deep unsymmetrical and obstinate ulceration ; and lead to extensive 
destruction with permanent loss of tissue and contraction. Thus, the 
uvula and soft palate may be more or less perfectly destroyed; the isthmus 
of the fauces may be narrowed ; stricture of the oesophagus may ensue : or 
destruction of the epiglottis, vocal cords, or other parts of the cartilaginous 
skeleton of the air-passages may take place; and, following upon these 
several lesions, loss of voice, difficulty of swallowing or breathing, and 
other serious or fatal consequences. Gummatous tumors also appear in 
the same parts, frequently in the tongue, where they may attain the size 
of a hen's egg, and sometimes in the connective tissue and muscles of the 
larynx. These not unfrequently assume many of the superficial cha- 
racters of epithelioma, and undergo the same processes as do subcutaneous 
gummata. 

Similar affections to the above take place in the male urethra and in 
the vagina and os uteri, as well as in the external parts of the organs of 
generation of both sexes; they also occur within the anus and in the 
lower part of the rectum ; and may, in all of these situations, in addition 
to other forms of mischief, lead ultimately to more or less serious contrac- 
tion or stricture. 

c. Organs of locomotion — Voluntary muscles are occasionally affected 
in the same way as the subcutaneous connective tissue. Gummata invade 
their texture, separating from one another their fibres, which then undergo 
degeneration. Such growths occur quite irregularly and may be mistaken 
for tumors of a far more serious character. We have already pointed out 
that they may form among the muscles of the larynx; they have also been 
observed implicating the masseter, the muscles of the scapula, and indeed 
those of most other parts. The bones are sometimes affected with diffused 
periostitis ; but more commonly nodes are developed on various parts of 
the long or flat bones, including the ribs, sternum, and bones of the face 
and skull. Nodes are gummatous growths in connection chiefly with the 
periosteum. They are usually extremely painful and tender, of various 
extent and prominence, more or less hard and unyielding at the periphery 
but elastic or even fluctuating in the centre. They seldom end in suppu- 
ration, and generally on healing leave some irregularity behind. Nodes 
do not usually result in caries or necrosis. A more frequent cause of 
these conditions is the extension of syphilitic ulceration in depth until 
subjacent bone is involved. But from one or other of these causes caries 
or necrosis may attack any bone ; the bones most frequently thus affected, 
however, are those of the nose, palate, and skull, to which may be added 
the cartilages of the larynx and trachea. The bones of the ear also may 
suffer. Syphilitic affections of the skull are generally limited to the outer 
surface and diploe, but occasionally involve the inner table as well, and are 
then apt to cause more or less serious cerebral symptoms. The joints occa- 



SYPHILIS. 



245 



sionally suffer, the surrounding soft parts becoming thickened and infiltrated, 
and the cavities distended with fluid effusion. 

d. Viscera The affections of the internal organs are scarcely so well 

known as those of the parts which have already been considered, but they 
are even more serious. The liver is perhaps their most frequent seat. 
The chief conditions which have been recognized here are, first, a more or 
less general hyperplasia of the connective tissue, especially of the capsule 
of Glisson, leading to a variety of cirrhosis ; and, second, the formation of 
gummy tumors which rapidly undergo degeneration, and by their contrac- 
tion cause puckering and fissuring of the surface of the organ. Either of 
these conditions may lead to the development of symptoms identical with 
those resulting from ordinary cirrhosis. The organs of circulation also 
are frequently implicated. The muscular tissue of the heart is occasion- 
ally the seat of diffuse fibroid infiltration or of more or less extensive 
gummatous formations, exactly like those involving the voluntary muscles. 
These induce degeneration of the tissue, induration, adhesion of pericar- 
dium, and the ordinary symptoms of progressive cardiac incompetence. 
There is good reason also to believe that some forms of arterial disease, 
and especially that form in which the inner coat undergoes a kind of 
nodular hypertrophy antecedent to the supervention of degenerative changes , 
are in many cases the result of syphilis. It is, at all events, certain that 
arteries frequently assume, this condition in those who are the subjects of 
syphilis, and who are suffering from gummatous tumors in other organs. 
And it is also certain that some of the lesions observed in the brains of 
syphilitic patients are essentially due to arterial changes of this kind, in- 
volving, however, not only the internal coat, but the adventitia, and to 
some extent also the middle coat, and leading to obstruction either directly 
or by thrombosis. Syphilitic affections of the lungs (gummata and fibroid 
infiltration) are described; nevertheless, their recognition is attended with 
much uncertainty. We have already adverted to the fact that the bron- 
chial tubes, like the larynx, may be distinctly implicated. But, besides 
bronchial lesions, there are not unfrequently found in the lungs of old syphi- 
litic patients scattered masses of hard grayish or blackish fibroid indura- 
tion, or caseous masses imbedded in such tracts of induration, which, 
although in many particulars resembling affections of tubercular or inflam- 
matory origin, are almost certainly gummata. The most grave of all 
tertiary syphilitic affections are those which involve the nervous centres. 
Gummatous tumors are developed in connection sometimes with the inner 
layer of the dura mater, sometimes with the pia mater, or the connective 
tissue of the brain substance. In the latter two cases the growths, which 
may attain the size of a pigeon's egg or even of a hen's egg, are, even if 
of peripheral origin, for the most part imbedded in the substance of the 
brain. Their most frequent site is the basal portion. Similar growths 
occur, though much less frequently, in connection with the spinal cord. 
The symptoms due to them are those of cerebral or spinal tumors. The 
cranial nerves and even the brain substance are occasionally the seat of 
syphilitic infiltration. Specific affections of the kidneys have been less 
thoroughly investigated; nevertheless, it is certain that these organs are 
sometimes affected, sequentially to syphilis, with diffused inflammatory 
processes, which induce atrophy, and that they are sometimes studded 
with distinct gummata, or with patches of cicatricial tissue, attended with 
corresponding linear or stellate contractions of the surface and having im- 
bedded in them small caseous masses. The testes are frequent seats of 



246 



SPECIFIC FEBRILE DISEASES. 



gummata, and also of diffused inflammatory processes. They are apt to 
become much enlarged ; occasionally suppurate ; and not unfrequently are 
associated with hydrocele. The lymphatic glands, as has been already 
pointed out, get enlarged and indurated secondarily to local syphilitic 
lesions; but occasionally, here and there in groups, they acquire such 
enormous dimensions as to simulate the enlargement of these organs due 
to scrofula, lymphadenoma, or cancer. Among other organs liable to 
syphilitic disease may be enumerated, the s,pleen, stomach, and bowels, 
mammae, and organs of special sense. 

The effects of syphilis do not end here. The long persistence of tertiary 
symptoms, with their frequent tendency to relapse, leads gradually but 
surely to a marked cachectic state of the system, indicated by sallowness 
and anaemia, •with relative increase of white corpuscles, emaciation and 
loss of strength, and lardaceous or amyloid degeneration of the liver, spleen, 
kidneys, and other parts, together with the additional symptoms to which 
such complications give rise. And finally may follow tuberculosis, or in- 
sidious but non-specific inflammations of various internal organs. 

4. Inherited syphilis presents some peculiarities which make it neces- 
sary to give the subject a brief separate consideration. It maybe derived 
from either the father or the mother, or from both. The effects of parental 
syphilis are not unfrequently manifested in the death of the foetus, and 
consequent abortion, at the latter period of pregnancy. The child is born 
dead, and more or less decomposed, but usually without distinct evidence 
of specific taint. In some instances, however, the placenta is affected with 
syphilitic disease. In other cases the infant is born alive, but shrivelled, 
puny, and unhealthy-looking; and large bulla? appear on the palms, or 
wrists, or the corresponding parts of the lower extremities. These blebs 
give rise to unhealthy sores, and the infant almost invariably dies speedily. 
In the majority of cases, however, the babe appears to be healthy at birth, 
and first gives evidence of disease after an interval of three or four weeks. 
The symptoms are mainly those of the secondary period of acquired syphi- 
lis ; but there are some features which are specially characteristic and im- 
portant, and to these alone attention will now be drawn. Among the 
earliest of these are, congestion and swelling of the nasal mucous mem- 
brane, with abundant secretion, giving rise to snuffles and other symptoms 
of chronic coryza ; diffuse inflammation of the mouth and fauces, with 
sores at the angles of the mouth ; mucous tubercles about the anus and 
similarly constituted parts; and a roseolous rash. The rash is generally 
most abundant on the buttocks, privates, and neighboring parts of the ab- 
domen and thighs, on the face, and on the palms and soles. It consists in 
circular patches from a line to half an inch in diameter, which either form 
lenticular elevations, or are slightly concave or cupped, and present there- 
fore a more or less tumid marginal ring. They vary in color, are some- 
times dusky red, sometimes brown or yellow, sometimes of a more or less 
coppery tint. They may be smooth or scaly, or may present superficial 
excoriation or erosion. The eruption on the palms and soles assumes a 
scaly character, and is attended with a tendency to crack and exfoliate. 
In association with the above phenomena the child becomes emaciated, 
its face assumes an old and weird character, its complexion grows sallow 
and unhealthy-looking, its skin dry and shrivelled, its hair scanty and 
thin, and not unfrequently it suffers from diarrhoea. These symptoms last 
probably for a few months, and have generally disappeared by the end of 
the first year. Somewhat later, generally from the age of four or five up 



SYPHILIS. 



247 



to that of puberty, the tertiary series of symptoms manifest themselves. 
These differ little from those which characterize the common tertiary stage. 
There are two or three however of peculiar and special interest, which now 
become apparent or develop themselves for the first time. One of them is 
flattening of the bridge of the nose, from sinking in of the subjacent carti- 
lages. Another is enlargement of the lower end of the humerus between 
the epiphysis and shaft. A third is a peculiar form of atrophy of the per- 
manent incisor and canine teeth. This is generally most marked in the 
upper two central incisors, and is often limited to them ; they are atrophied, 
peg-like, and present towards their free edge a reniform or cordate cha- 
racter — the notch occupying the centre of this edge. This condition is 
traceable to the effect, on the tooth-germs, of the stomatitis from which the 
children have previously suffered. The last of them is interstitial kera- 
titis, that is, an interstitial inflammation of the cornea, marked by increas- 
ing cloudiness and opacity of the part, and attended with a vascular zone 
in the sclerotic, and more or less intolerance of light. There is no vesi- 
cation or ulceration, and the opacity speedily diminishes under appropriate 
treatment. The recognition of the last two affections is due to Mr. J. 
Hutchinson. 

It would be impossible in a brief space to discuss the differential diag- 
nosis of syphilis. It must be sufficient to say that the manifestations of 
syphilis simulate a vast range of different diseases ; and further that 
syphilis necessarily often occurs in persons who are the subjects of skin- 
affections and various other disorders, and often exerts a modifying influ- 
ence over these ; and that hence it is frequently quite impossible to form 
an exact diagnosis, without going fully into the history of the patient's 
case, and taking into careful consideration all the facts of his past history 
and present condition. 

Morbid anatomy and 'pathology In the foregoing description of the 

phenomena and sequelae of syphilis we have necessarily, to a large extent, 
discussed the pathological processes of the disease and its morbid anatomy. 
It remains, however, to give a brief connected account of these subjects. 
The morbid poison which enters the system at the time of inoculation is 
doubtless a living entity or contagium, which imparts specific properties, 
primarily to the growth which it directly induces, and secondarily to the 
vital constituents of the enlarging lymphatic glands situated next above 
that growth. Possibly from the primary sore, more probably, however, 
from the group of morbid lymphatic glands, as a centre, is shed into the 
blood-stream newly manufactured contagious matter (probably particulate) ; 
which in its turn infects in different proportions and in different order the 
various organs and tissues of the body, producing in them specific pro- 
cesses which have a more or less close resemblance to those out of which 
they arose, and which like them are infectious certainly to other persons, 
and probably like carcinoma to the individual. The early series of general 
phenomena (those for the most part which belong to the period of second- 
ary symptoms) differ scarcely at all in their anatomical characters and in 
their local results from simple inflammatory processes. There is conges- 
tion, proliferation of connective-tissue imitative of granulation-tissue, and 
a tendency in the new formation, after a temporary persistence, to subside 
altogether so as to leave no trace whatever behind, or to merge into the 
tissues, in relation with which it appears — if in relation with connective- 
tissue into connective-tissue, if in relation with bone into bone, if in the 
matrix of the liver, kidney, lung, testicle, or brain, into nucleated fibrous 



248 



SPECIFIC FEBRILE DISEASES. 



tissue and to produce therefore in these organs induration, contraction, and 
atrophy. The later phenomena (those which belong chiefly to the tertiary 
stage) consist in the formation of adventitious growths, termed gummata, 
which are identical in structure with primary chancres and the primarily 
indurated glands. They consist like them of cell-growth, differing little 
microscopically from ordinary granulation-tissue, and in this respect there- 
fore little from the secondary lesions, but presenting certain special features. 
Thus they do not so much displace as infiltrate or involve the tissues among 
which they arise ; they have a remarkable tendency to undergo speedy 
caseous degeneration, and to cause molecular or fatty disintegration of the 
higher elements which are mixed up with them ; if developed in internal 
organs, they acquire for the most part permanence as either caseous lumps, 
earthy concretions, indurated fibrous patches, or morbid tracts in which all 
of these conditions are variously combined ; and if they be developed in 
superficial parts, such as the skin, mucous membranes or superficial bones, 
their degeneration results in the formation of crusts, ulcers, abscesses or 
sloughs, with more or less serious destruction of tissue. Gummatous 
tumors, while in process of development, vary in their physical characters ; 
thus, sometimes they are grayish, firm, and translucent or opaque ; some- 
times (especially when they form beneath the skin and mucous mem- 
branes) they are infiltrated with a mucus-like fluid, which oozes away when 
they are laid open. 

There is undoubtedly a resemblance both anatomically and functionally 
(at all events as regards their infectiveness) in all the congestive or proli- 
ferating lesions which depend for their origin on the syphilitic virus. And 
although a line may be drawn, both on clinical grounds and for the pur- 
poses of description, between secondary and tertiary phenomena, and 
although it is quite true that the later lesions are far more serious and 
virulent than those which precede them, there is no doubt that they pass 
one into the other, that they shade off the one into the other by numerous 
gradations, and that they are often blended ; so that while, on the one 
hand, gummatous tumors may occur during the secondary period, second- 
ary eruptions may be met with late in the progress of the disease. 

Treatment — For the prophylactic treatment of syphilis, and for the 
treatment of the primary affection, reference must be made to surgical 
works. The inoculation of syphilis upon healthy persons, which has been 
so extensively practised by Boeck, and advocated by others, in order that 
by giving them the disease it might affect them in a mild form and pre- 
vent any future attack in a graver form, seems to us, we confess, not only 
dangerous but altogether unjustifiable. It is now generally admitted that 
syphilis, like other specific febrile diseases, is incapable of absolute cure, 
and that it will run a definite course in respect of duration, no matter 
what steps are taken to arrest its progress. It is nevertheless certain that 
we have at least two remedies which exert a remarkable influence over its 
various localized manifestations, which subdue them almost to zero if they 
do not absolutely annul them, and which keep the general disease in abey- 
ance even if they fail (as they probably do) to extinguish it altogether. 
These remedies are mercury and iodine in their various preparations. The 
value of mercury was early established, and has indeed only lately been 
regarded with suspicion. But this suspicion arose doubtless out of the 
injurious influences which the abuse of mercury engendered during the 
earlier part of this century, and was supported by the recognition of the 



SYPHILIS. 



249 



fact that the free use of mercury failed in many cases to prevent the super- 
vention of secondary symptoms. It is admitted now that mercury does 
not prevent either secondary or tertiary symptoms from coming on ; but 
nevertheless it is certain that it has a marvellous influence in causing the 
removal, in turn, of the primary, secondary and tertiary lesions of the 
disease. The form, the dose, the mode, and the length of time in which 
the drug should be administered are points on which there is much differ- 
ence of opinion. Some prefer to introduce it by the inunction of strong 
mercurial ointment on the inner aspect of the thigh or other parts in which 
the integuments are thin : in this case from half a drachm to a drachm of 
the ointment may be rubbed in every night before the fire. Others affect 
the practice of fumigation by means of volatilizing calomel with the heat 
of boiling water. The drug may by this means be inhaled, or applied to 
the general surface, or to particular regions, with little difficulty. For 
inhalation, not more than four or five grains of calomel should be employed. 
Others again recommend that the mercury should be administered by the 
mouth. For this purpose any mercurial preparation in an appropriate dose 
is applicable. But the most convenient, and possibly the best, is corrosive 
sublimate or the red iodide of mercury, of which from ~ to -| gr. may be 
given three times a day, or equivalent doses of the liquor hydrargyri per- 
chloridi. The treatment should be continued until the lesions have dis- 
appeared under its influence, and even for a week or two longer, and the 
quantity should be regulated by its effects on the system, slight soreness of 
the gums only being maintained. Iodine is almost equally valuable with 
mercury ; but it seems to have a special value during the later periods of 
the disease, in which (when the lesions prove intractable) it may often be 
beneficially combined with the mercurial treatment. The usual, and pro- 
bably on the whole the best, form is the iodide of potassium in from 5- to 
10-grain doses three times a day, combined with a tonic. [Cases will, 
however, be occasionally met with in which it will be necessary to pre- 
scribe much larger doses than these. In cerebral syphilis, for instance, 
it will frequently happen that marked improvement will follow the ad- 
ministration of half a drachm three times a day, in cases in which 10- 
grain doses have failed to produce the slightest effect. Moreover, these 
large doses are perfectly well borne, the patient often growing fat while 
taking them.] The syrup of the iodide of iron is very valuable in many 
cases, and especially for young children. Bromine has an antisyphilitic 
power similar to that of iodine, and is sometimes substituted for it. Among 
other anti-venereal remedies which have acquired and still enjoy a wide 
reputation are sarsaparilla, and nitric acid in large doses. They have 
probably no specific virtues at all. Tonic medicines — quinine, iron, cod- 
liver oil and the like — are often of immense value in the treatment of the 
cachexia which attends the later stages of the disease. The value of 
local applications to syphilitic lesions is undoubted : the most important of 
these are the mercurial and the iodic, among which may be enumerated 
powdered calomel, black-wash, mercurial, citrine or iodine ointment, iodide 
of starch paste, and localized calomel fumigations — one or other being 
employed according to the nature of the lesion, and the convenience and 
relative safety of its applicability. 



250 



SPECIFIC FEBRILE DISEASES. 



XXIII. PYAEMIA. (Septicemia.) 

Definition. — By the term 'pyemia' is understood a febrile and generally 
acute disorder, due to the entrance into the blood of certain poisonous or 
septic, for the most part inflammatory, products, and usually characterized 
by the blocking up by clots or emboli of the arterioles of the lungs and 
other organs, and the consequent occurrence therein of scattered patches 
of congestion, hemorrhage, inflammation, suppuration, or gangrene. 

Causation The conditions out of which pyaemia arise are very numer- 
ous and various. First, it is a frequent sequela of accidental injuries, such 
as burns, scalds, bruises, and lacerations, and compound fractures, espe- 
cially of the long bones, and of the bones of the head and pelvis. Second, 
it frequently ensues on surgical operations, especially those which are 
attended with the formation of extensive raw surfaces, such as amputations 
of the larger limbs, and also those involving bone, bladder, prostate, ure- 
thra, or rectum. To these must be added operations on veins, such as 
phlebotomy and operations for the cure of varicose veins and hemorrhoids. 
Third, pyaemia occurring after parturition constitutes one of the most com- 
mon and fatal forms of so-called i puerperal fever.' Fourth, pyaemia not 
very unfrequently originates in acute suppurative inflammation taking 
place at the surface or in the substance of bones — cases in which, as a 
rule, the periosteum becomes extensively detached, and the bone necrotic. 
Fifth, many varieties of so-called unhealthy inflammation, such as ery- 
sipelas, diffuse cellular inflammation, carbuncle, dissection-wounds, and 
malignant pustule, are often fatal on account of the supervention of this 
complication. It may be added that when pyaemia manifests itself after 
injuries or operations, it is generally preceded by some obviously unhealthy 
condition of the implicated tissues ; and also that pyaemia is far more liable 
to originate in affections of certain organs and tissues than in those of 
others. Among the former may be included the connective tissue gene- 
rally, the bones, the pelvic organs both in the male and female, and the 
veins. That pyaemia is in a large number of cases imparted by contagion 
is quite beyond dispute. It is thus that it often spreads in the surgical 
wards of a hospital, and among the puerperal inmates of a lying-in institu- 
tion. In all such cases there is good reason to believe that it is transmitted 
from patient to patient by direct inoculation at the raw surfaces of wounds 
or of the placental area; or rather that, not so much pyaemia is transmitted 
directly from patient to patient, as some form of erysipelatous or other un- 
healthy inflammation is thus transmitted, of which pyaemia is a common 
accident. It is certain, on the other hand, that even when it complicates 
the puerperal state and surgical wounds, it often arises, so far as we can 
discover, de novo, and altogether independently of specific influences. 
There can be but little doubt that it is very frequently, if not always, of 
idiopathic origin when it occurs without breach of surface. It still remains 
to consider whether there are any special conditions of system and of a 
patient's surroundings which render him peculiarly liable to become pyaemic. 
In reference to this point it may be remarked that age and sex have no 
distinct influence ; that patients apparently in the best of health are often 
struck down with pyaemia ; and indeed, that when pyaemia pervades a 
ward, it by no means selects the weakly and the cachectic in preference 
to the robust and healthy-looking ; and, again, that it does not arise with 



PYEMIA. 



251 



special frequency in connection with either simple overcrowding, bad ven- 
tilation, or common filth. 

Morbid anatomy and pathology. — The post-mortem phenomena which 
characterize the presence of pyaemia are (as stated in our definition of the 
disease) patches of congestion, hemorrhage, inflammation, suppuration or 
gangrene, disseminated more or less abundantly throughout the organs and 
tissues of the body. These are most common in the lungs, and are often 
confined to them. We find here, irregularly scattered but mostly abut- 
ting on the surface, circumscribed patches ranging from the size of a pea 
to that of a walnut. These are sometimes distinctly apoplectic, in which 
case they may be reddish-black or more or less decolorized, solid or partly 
broken down into a puriform pulp ; sometimes they present the ordinary 
characters of lobular pneumonia ; sometimes they are simple abscesses or 
gangrenous cavities. These different characters depend in part no doubt 
on the stage at which death has taken place, but are often due to individual 
peculiarities. There is usually more or less congestion and oedema of the 
general lung-tissue, and occasionally diffused pneumonic consolidation and 
secretion of mucus into the bronchial tubes. There is probably always a 
deposit of pleural lymph over and around each pyaemic lump which involves 
the surface of the lung; and not unfrequently general pleurisy ensues. 
Sub-pleural petechias are common. The surface of the heart, like that of 
the lungs, is often studded with small extravasations of blood ; as also are 
the substance of the cardiac w r alls, and the sub-endocardial tissue. And 
sometimes, generally in relation with these extravasations, small yellowish 
patches of disintegrating tissue or abscesses may be discovered. When 
these reach the inner or outer surface of the heart they are apt to provoke 
inflammation of that surface. Neither pericarditis nor endocarditis is of 
rare occurrence. Of the abdominal organs, the liver, spleen, and kidneys 
most frequently suffer. In the liver, generally in connection with patches 
of congestion or of anaemia, we sometimes find small buff-colored spots of 
disintegrated tissue, sometimes abscesses of considerable size full of greenish 
purulent fluid. The morbid conditions presented by the spleen and kid- 
neys are almost exactly such as are met with in embolism or thrombosis of 
the vessels of these organs. In the spleen we observe apoplectic or fibrinous 
blocks of various sizes, which have often undergone more or less disinte- 
gration and softening, or even conversion into abscesses. The kidneys are 
sometimes studded (chiefly in the cortex) with small abscesses, grouped 
for the most part in lines perpendicular to the surface and surrounded by 
a halo of congestion. Occasionally no abscesses have formed, but almost 
the whole of their tissue is mapped out by tracts and bands of deep con- 
gestion, which alternate with and surround patches of which the color is 
unnaturally pale. Spots of hemorrhage, patches of inflammation, or small 
abscesses may be present in any other of the abdominal organs, sometimes, 
for example, in the intestinal wall ; and the peritoneum may be affected 
exactly in the same way as the pleurae and pericardium. The brain is not 
very commonly the seat of pyaemic changes ; the extravasations of blood 
are generally small in amount and limited to the surface; patches of soft- 
ening exactly like those due to embolism, excepting that they rarely ex- 
ceed the size of a horse-bean, may occur in any part of the organ ; abscesses 
containing greenish-yellow glairy pus attain a much larger size. Meningitis 
also occurs. The bones and joints are frequently involved. The second- 
arily affected bones rapidly become denuded of periosteum, and fetid pus 
accumulates upon their surface and probably in their substance, and rapid 



252 



SPECIFIC FEBRILE DISEASES. 



necrosis ensues. The synovial fringes of the joints get intensely congested, 
and the synovia increased in quantity or replaced by pus or puriform fluid. 
The cavities of the joints become distended, and the parts around inflamed. 
It is important to bear in mind that suppuration may occur in the neigh- 
borhood of joints without involving them, and that pyremic inflammation 
of joints is not always suppurative. It must be added to the foregoing 
account that secondary inflammations, suppurative or not, frequently mani- 
fest themselves in the connective tissue and among the muscles; and that, 
of organs which have not been specially named, the eye, the prostate, and 
the testis are very apt to suffer. The skin never presents any character- 
istic change ; but it is often slightly jaundiced, and occasionally presents 
petechias ; sudamina are common. 

The condition of the blood and bloodvessels in pyaemia is a matter of 
great interest. The bulk of the circulating fluid, and the vessels in the 
greater part of their extent, have usually the aspect of perfect health. The 
coagula, indeed, which are found post-mortem in the heart and larger ves- 
sels usually differ in nothing from coagula found under other circumstances ; 
very rarely a few soft masses of disintegrated fibrine or of corpuscles re- 
sembling pus may be found imbedded in them. But, with this exception, 
it is only in the arteries which lead to the secondary morbid patches, and 
in the veins involved in the primary lesion, that visible morbid phenomena 
are present. The minute arteries distributed to each patch of pulmonary 
disease are always found filled and obstructed either with ordinary thrombi 
or with a soft yellowish material, consisting of disintegrated fibrine and 
corpuscles, or in some cases of these mingled with what appear to be groups 
of pus-cells. Similar coagula have been detected in the small vessels 
leading to the diseased patches occurring in the heart, spleen, and kidneys, 
and doubtless are always present in the arteries which are connected with 
the generalized pyaemic lesions. The veins which are involved in the 
primary inflammatory process are in a very large proportion of cases ob- 
viously diseased. It is true that, even after careful dissection, they have 
in some cases appeared to be entirely healthy. But when we bear in mind 
that in other cases the presence of diseased veins has only been detected 
after some hours of minute investigation, we shall see reason to suspect 
their existence in cases where they have been reported to be absent. When 
diseased, their parietes are thickened and indurated ; they may be entire, 
or may communicate by orifices resulting from ulceration or some other 
cause with the morbific elements in which they are imbedded ; and their 
interior is occupied by coagula. These are mostly adherent, and more or 
less decolorized ; they may be solid throughout, but more commonly are 
reduced in their interior into a reddish or yellowish pus-like pulp or fluid. 
This appears generally to consist of disintegrated fibrine, but is in some 
cases true pus. It is mostly separated from the venous walls by a layer 
of fibrine, and shut out from the proximal portion of the venous channel 
wherein it lies by a continuation of this layer of fibrine, which forms a 
kind of diaphragm or septum between them. In some cases no mechanical 
impediment whatever exists to prevent the free admixture of the pus con- 
tained in the vein with the general circulation. 

We are now in a position to discuss the proximate cause of pyasmia. It 
was formerly supposed that the secondary inflammatory patches were mere 
deposits of pus which had been absorbed as such by the veins and carried 
to the localities in which abscesses were found. But, unfortunately for 
this view, pus as such is not found to circulate with the blood, and the 



PYAEMIA. 



253 



secondary patches of disease are never in the first instance, and not often 
at any time, distinctly purulent. The theory of embolism, however, here 
comes to our aid. There is no doubt that the secondary foci of disease 
are almost exactly such as would be produced by embolism of the arteries 
leading to them ; and we find, in fact, that these arteries are really plugged. 
But we find, further, that these plugs are identical in composition and 
appearance with the coagulated material which blocks up the veins of the 
primarily inflamed region. It is reasonable, therefore, to assume that the 
diseased veins are really the sources of emboli, which, becoming impacted 
in the pulmonary arteries, induce characteristic changes in the parts be- 
yond, and that the phenomena of pyaemia are, therefore, in large measure 
due to the dissemination in pellets of the morbid matters — pus, disinte- 
grated clot, and the like — which these veins contain. In favor of this 
view are the facts that such pellets have been recognized in transitu, and 
that pyaemia is especially liable to occur where veins have been the subject 
of operation, and where inflammation attacks parts in which the veins are 
abundant and large, thin-walJed, or incapable of collapsing — such parts, 
for example, as the contents of the pelvis, the uterus, a*'ter parturition, the 
cancellous structure of bones, and the meninges of the brain. There can 
be little doubt indeed of the correctness of the above explanation, so far 
as it goes, and little doubt also that the quality of the emboli has a marked 
influence over the quality of the processes which they induce ; and that 
hence whether these latter be gangrenous, suppurative, or simply inflam- 
matory, depends in no small degree on the special nature of the process 
going on in the primary seats of disease. But will embolism alone ex- 
plain all the phenomena of pyaemia? To this question Virchow replies in 
the negative. He considers pyaemia to be a twofold disease, comprising, 
in the first place, phenomena due to embolism, and, in the second place, 
phenomena due to the absorption of some more subtle poison. These latter, 
which he regards as the more important, have been collectively termed 
' septicemia,' and he considers that these two groups of phenomena may 
occur independently of one another. A very strong argument in favor of 
this view r is the fact that patients occasionally die with many of the ordi- 
nary symptoms of pyaemia, arising from some unhealthy wound, in whom 
no morbid conditions whatever can be discovered post mortem, save con- 
gestion of various internal organs, small extravasations of blood beneath 
the serous membranes and elsewhere, and tendency to rapid decomposition. 
Such cases, which are very acute in their progress, are not unfrequently 
met with in the course of the endemic prevalence of pyaemia, and are re- 
garded by many as cases in which death has supervened before the specific 
lesions have had time to develop themselves. The discovery of bacteria 
in the blood of pyaemic patients is a matter of interest, and (although they 
are also discoverable in the blood of patients who are not pyaemic and 
never become so) the interest attaching to their presence is greatly en- 
hanced by the observations already referred to (p. 143), which seem to 
prove that when they swarm in a putrefying surface they evolve a poison 
which is capable of absorption and of producing symptoms having some 
resemblance to those of pyaemia. So far, then, as our present knowledge 
goes, pyaemia (using this term in its w T idest sense) seems to be due to the 
introduction into the circulating blood, through the medium of certain im- 
plicated vessels, of showers, so to speak, of septic products, these being 
partly solid, in part probably fluid, and charged more or less distinctly 
with the special properties of the local inflammation or process which gave 



254 



SPECIFIC FEBRILE DISEASES. 



them origin. The presence of these in the blood causes in the first in- 
stance, partly by embolism, partly by thrombosis, obstruction of the pul- 
monary arteries with certain characteristic lesions in the lungs-, and at a 
later period obstruction of various of the systemic arterioles with similar 
characteristic lesions in the districts which they supply. It imparts also 
specific poisonous properties to the blood. It is easy to understand from 
this view how it is that, when pyemic processes are present, the lungs 
are, as a rule, affected both earlier and more extensively than other organs. 

Symptoms and progress — The symptoms which usher in an attack of 
pyaemia are generally well-marked, unless the condition of the patient or 
the nature of the disease under which he is laboring at the time confuses 
them. The first symptom to attract attention is almost without exception 
a sudden, severe, and prolonged rigor, followed by profuse perspiration. 
The patient may recover from this, and for a time appear to be restored 
to health. But before long, it may be the next day, or at some earlier 
period, the rigor returns with its after sweating stage; and again and 
again, at varying intervals, rigors and sweats recur. In the course of a 
day or two the conjunctivae and skin assume a sallow tinge ; the patient 
becomes dull and heavy, or it may be restless, and acquires very much the 
manner and aspect of a person suffering from some form of continued fever. 
In company with the above symptoms, or in succession to them, others of 
more or less importance show themselves. The pulse becomes rapid, weak, 
and perhaps intermittent. The tongue becomes glazed and fissured, or 
coated, and after a time dry and brown, the lips parched, the teeth covered 
with sordes. The patient is thirsty, loses his appetite, suffers often from 
nausea and vomiting, and not unfrequently from diarrhoea. The respira- 
tions become shallow and frequent, and the respiratory acts attended with 
dilatation of the nares or separation of the lips, and either a sniffing, sip- 
ping, or sucking sound. Cough often supervenes, attended probably with 
pains in the chest, and evidences of pleurisy or consolidation of the lungs, 
and of excessive secretion into the bronchial tubes. The skin, in the in- 
tervals between the perspirations and rigors, is often dry and harsh, and 
may present sudamina. The sallowness generally increases, and often 
amounts before death to well-marked jaundice. Pain and swelling in or 
around joints, or in other parts of the connective tissue, often present 
themselves, and pus may form rapidly in these situations. As the disease 
advances the patient becomes excessively prostrate, his face shrunken, and 
for the most part pale, his mental functions disturbed ; slight delirium 
comes on, sometimes coma, sometimes convulsions ; and death ensues 
usually in from four to ten days. Sometimes pyaemia takes a more chronic 
course: the symptoms are then altogether less strongly pronounced, the 
fever assumes the characters of hectic fever, abscesses form in the joints 
and other superficial parts, and the patient sinks from exhaustion at the 
end of a few weeks or even a few months, or in rare cases recovers after 
a protracted convalescence. 

We will consider some of the symptoms of pyaemia more in detail. 

The patient's aspect may at first be healthy-looking or nearly so, but 
soon becomes dull and oppressed. The face is sometimes flushed, some- 
times pallid, and often these conditions alternate. Towards the close of 
the disease pallor generally becomes established, and the countenance 
shrunken and anxious, or of that dull expressionless aspect which is com- 
mon in the last stages of many febrile disorders. Rigors, though occa- 
sionally absent, constitute one of the most striking phenomena of pyaemia. 



PYEMIA. 



255 



They vary in number and frequency, sometimes recurring at short and 
irregular intervals, sometimes assuming a quotidian character, and gene- 
rally ceasing after the first two or three days. Their duration ranges 
from a few minutes up to half an hour. The temperature of pyaemia has 
a good deal of resemblance to that of ague ; the rigors are always attended 
with a rapid rise, which is followed by an almost equally rapid fall. Dur- 
ing, or after, the first rigor, the temperature may reach 104°, 105°, or 
even 107°, or more, and the subsequent fall carries it down probably to a 
little above the normal, occasionally even below it. Subsequently, accord- 
ing to circumstances, the temperature may present a succession of similar 
elevations and depressions, or maintain a nearly uniform level. Death 
may be preceded by either a normal, a low, or even a very high tempe- 
rature. The skin, which is often harsh and dry, perspires profusely after 
the rigors, and copious perspirations recur from time to time during the 
progress of the malady, and attend its last stage. 

The respiratory acts, as the disease advances, become frequent, inde- 
pendently of the presence of pulmonary complication, and not uncommonly 
reach 40, 50, or 60 in the minute; and the breath is said to acquire a 
peculiar sweet odor. The pleuritic exudation, the pulmonary lesions, and 
the excessive formation of bronchial mucus, may each or all aggravate the 
symptoms due to the respiratory organs ; and may induce dyspnoea, cough 
with various forms of expectoration, pleuritic stitches, and friction, crepi- 
tation, rhonchus, or other auscultatory phenomena. 

The feebleness of the pyaemic pulse is remarkable. It is generally rapid 
from the beginning, or, if not rapid, variable, so that the slightest exertion 
of body or mind raises it 20, 30, or even 40 beats in the minute. As the 
disease advances, it frequently rises to 140 or 160 in the minute, and may 
even reach 200; it then tends to become irregular and almost impercep- 
tible. It is possible that pericardial friction or other signs of cardiac im- 
plication may be present. 

Abdominal pain and tenderness may be caused by the presence of he- 
patic or splenic congestion or inflammation, or of circumscribed peritonitis 
in connection therewith. The jaundice, which is so common in pyaemia, 
appears to be quite independent of the presence of pyasmic deposits and 
abscesses in the liver. Frerichs remarks that, i to all appearance the 
jaundice is here the result of an impaired consumption of bile in the blood, 
arising from an abnormal condition of the metamorphic processes which 
go on in that fluid.' 

Urea is largely increased, and often the urine contains a small quantity 
of albumen. 

Arthritic and other superficial abscesses are far more common in the 
chronic than in the acute form of pyaemia. Their formation is mostly 
indicated by the usual symptoms which attend such inflammation. Some- 
times, however, they come on rapidly and with little or no pain. 

The nervous symptoms are much like those which attend typhus and 
some other specific fevers. They vary, but comprise in the first instance 
either restlessness or apathy and drowsiness, and later on delirium, which 
may be violent, but is generally muttering, and often passes into coma. 
Muscular debility is always well-marked from the beginning, and soon 
becomes extreme. There are often tremors or subsultus, and sooner or 
later loss of control over the bladder and rectum. 

The time at which pyaemia arises in relation to the morbid condition 
on which it supervenes varies. In accident and operation cases, and in 



256 



SPECIFIC FEBRILE DISEASES. 



those of carbuncle and erysipelas, it may come on at any moment from 
the commencement of suppuration up to the period of complete recovery. 
In cases of acute suppuration connected with bone, and acute necrosis, 
pyaemic symptoms are sometimes present almost from the first. In puer- 
peral cases pyaemia usually manifests itself between the third and the 
tenth or twelfth day after labor. As regards those cases in which infarcts 
or pyaemic formations are not found after death, in which therefore there 
is reason to believe that the symptoms during life have been due to the 
absorption of poisonous fluids only, and to which (if to any) the term sep- 
ticaemia (as distinguished from that of pyaemia) is specially applicable, 
it may be observed that the symptoms have a good deal of resemblance to 
those developed in animals into whose tissues septic fluid has been injected 
in poisonous doses. There is not generally any rigor, or if there be it is only 
at the commencement ; but among the more striking phenomena, are men- 
tal apathy or delirium, vomiting and diarrhoea, great dryness of tongue, 
feebleness and rapidity of pulse, perspirations, extreme muscular debility, 
and rise of temperature. The temperature, however, often sinks as death 
approaches, and sometimes becomes sub-normal. 

The prognosis of pyaemia is exceedingly unfavorable. There is little 
doubt that recovery does occasionally take place ; at the same time it rarely 
happens that this event ensues in cases which, from the severity of their 
symptoms, are distinctly recognized as pyaemic during life. The cases of 
recovery are usually those in which the symptoms from the beginning are 
mild, and which would probably not be recognized as pyaemic but for the 
fact of their occurrence during the endemic prevalence of the disease in the 
wards, say of a lying-in hospital ; or they are cases of simple septicaemia. 

There is generally not much difficulty in the diagnosis of pyaemia when 
it arises after surgical injuries or parturition. There is much more diffi- 
culty when it occurs in patients who are already prostrated by acute 
inflammatory affections, such as carbuncle or erysipelas, the symptoms due 
to which indeed are not unlike those of pyaemia itself. And it is particu- 
larly apt to be misunderstood when it arises out of some deep-seated sup- 
puration. The diseases for which it may be especially mistaken, and for 
which it has been mistaken over and over again, are typhus and enteric 
fevers, internal acute inflammations (especially of the lungs), urethral and 
bladder affections in which the kidneys have become involved, glanders, 
and acute rheumatism. It may be added that it is a good rule, when a case 
comes under treatment in which typhoid symptoms with great prostration 
have develop ed themselves very rapidly, and in which from the absence of 
any specific symptom the physician hesitates to form a definite diagnosis, 
to examine the limbs and surface of the body carefully. It has more than 
once happened to the writer in such cases to recognize, by the increased 
bulk of a thigh or arm, the source of the symptoms in the existence of a 
sub-periosteal abscess. 

Treatment. — Very Utile, unfortunately, can be done medically for a case 
of pyaemia. We cannot cure the complaint ; we cannot arrest it ; we 
cannot, so far as we know, eliminate from the system any poisonous matter 
to which it may be supposed to be due. Quinine has been exhibited with 
the object both of checking the periodic rigors, and of reducing excessive 
temperature ; cold baths also have been used with the latter object ; hot 
baths have been employed to promote perspiration, purgatives to aid eli- 
mination from the bowels, antiseptics of various kinds to obviate the sup- 
posed putrefactive tendency of the disease. But all to little purpose. 



LEPROSY. 



257 



Our main aim must be, on the one hand to support the patient's strength 
by regulated and suitable diet and the moderate employment of stimulants, 
in aid of which vegetable tonics in combination with the mineral acids are 
often useful; on the other hand, to relieve, as far as maybe, all distressing 
symptoms and injurious complications, for which various purposes no drug 
is so generally useful as opium or morphia. It should be added that, where 
symptoms suggestive of pyaemia show themselves, it is of the utmost im- 
portance to attend to the condition of the part which is its supposed source; 
not so much, however, for the purpose of arresting pysemia in actual pro- 
gress as of preventing the occurrence of what may perhaps only threaten. 
Unhealthy wounds should be freely laid open, deep-seated abscesses freely 
incised, and, if deemed necessary, antiseptic or caustic injections or appli- 
cations freely employed. 

In surgical and obstetrical practice, especially that of hospitals, the 
question of the prevention of the spread of pysemia is one of the highest 
interest. No doubt pyaemia very frequently occurs spontaneously among 
both surgical and obstetrical patients. But, whenever either pyaemia or 
erysipelas, no matter how it has originated, appears among groups of such 
patients, we know that there is a remarkable tendency for it to spread. 
To obviate this tendency, extreme cleanliness, ample ventilation, scrupu- 
lous nicety Avith respect to the treatment and dressing of raw surfaces, and 
especially the utmost care not to allow infection to be conveyed from one 
to another by the fingers of the medical and other attendants, are essen- 
tial. The extreme value of Professor Lister's antiseptic method of ope- 
rating and treating raw surfaces is now almost universally acknowledged. 



XXIV. LEPROSY. {Elephantiasis Grcecorwn.) 

Definition A specific disease, endemic in many parts of the world, 

characterized by the slow development of nodular growths in connection 
with the skin, mucous membranes, and nerves, and (in the last case) by 
the supervention of anaesthesia, paralysis, and a tendency to ulcerative 
destruction and gangrene. 

Causation and history. — Leprosy is a disease which has doubtless been 
largely confounded with other maladies, such as elephantiasis Arabum, 
syphilis, and various affections of the skin, but has yet been recognized 
from the earliest times, has been described under various names, and has 
been regarded with perhaps more general superstitious awe and dread than 
any other known disease. It was probably not uncommon throughout 
Europe during the first two-thirds of the Christian era ; but there is no 
doubt that it underwent a marvellous increase during the twelfth and 
thirteenth centuries. An epidemic wave seems then to have spread slowly 
from the southeast to the northwest ; and it was assumed, indeed (though 
probably erroneously), that at that time it was imported into Europe by 
the returning Crusaders. The disease prevailed generally with great 
severity during the succeeding two or three hundred years, then began to 
subside, and had finally disappeared from the greater part of Europe by 
the end of the seventeenth century. This subsidence of leprosy was 
closely related in time with the asserted introduction of syphilis ; and 
hence it has been maintained (in spite of the clearest proof to the con- 
17 



258 



SPECIFIC FEBRILE DISEASES. 



trary) that these diseases are co-related, and their manifestations mere 
modified results of the operation of the same virus. But although the 
greater part of Europe became thus free at the date above assigned, the 
disease lingered in the Faroe Isles up to the commencement of the present 
century, and still prevails in certain parts of Italy, Greece, Spain, Portu- 
gal, and Russia, and with especial severity in Norway, Sweden, and Fin- 
land. At the present day, however, leprosy is mainly a disease of tropical 
and sub-tropical climates, and among these its chosen habitats are, perhaps, 
Central and Southern Africa, India and China, and the West Indies, and 
South America. The etiology of leprosy has been largely discussed. 
Temperature, climate, soil, race, habits, food, have all been regarded as 
predisposing, if not exciting, causes. That temperature has no obvious 
specific influence is manifest from the fact that the disease prevails alike 
in Norway and in India. That the soil and climate are equally inopera- 
tive is shown by the fact that it occurs both on marshy soils and at high 
elevations, both on the sea-coast and in inland regions, both in continents 
and in islands, and in nearly all latitudes. At the same time it is worthy 
of note that a large number of the localities which it specially affects are low- 
lying and marshy, and on the sea-coast or banks of rivers. That race and 
habits are not specific causes is clear from the prevalence of the disease 
amongst races of the most diverse kinds, and amongst persons of the most 
opposite habits. Yet it may probably be admitted, and has been asserted, 
that of several races living associated together and under many similar con- 
ditions, some are more prone to leprosy than others ; and also that the dis- 
ease is on the whole more common among the poor and filthy than among 
the well-to-do and cleanly. As regards the influence of diet, it may be 
pointed out that it has been attributed to the use of decomposing fish; but, 
unfortunately for this theory, the disease is met with where not only fish 
is never eaten, but where the diet is mainly vegetable. It follows neces- 
sarily that if the cause of leprosy reside in any of the conditions which 
have been enumerated, that condition has at all events as yet escaped 
recognition. Formerly the disease was regarded as highly contagious, 
and consequently all communication between the sick and the healthy was 
rigorously interdicted. At the present day, however, its contagiousness 
is almost universally denied by scientific medical men ; and it is beyond 
doubt that the attendants on the sick apparently fail to take it, that chil- 
dren live habitually in the same house with leprous members of their 
family without becoming affected, and that even sexual cohabitation may 
go on for years without the disease being transmitted from the diseased 
person to the healthy one. On the other hand, it seems to be clearly es- 
tablished that the disease is to a considerable extent hereditary — heredi- 
tary, that is to say, in the same sense as tubercle and carcinoma are 
hereditary, but not in the sense in which syphilis is hereditary. In other 
words, it appears, not that children are ever born with leprosy, but that 
the children of leprous parents are more likely to become affected than 
are the children of healthy parents — a fact which probably explains the 
supposed influence of race. It must indeed be admitted that the causes of 
leprosy, of its generally endemic character, and of its occasional epidemic 
prevalence, are alike unknown. That the disease has a specific character 
is quite clear; and that the tendency to it (if not the disease itself) is 
transmissible from parent to child is equally clear. But whether it be- 
longs to that class of diseases which is represented by tubercle and carci- 
noma, or whether, like ague and goitre, it is the result of some obscure 



LEPROSY. 



259 



telluric condition, or whether, like scurvy and ergotism, it is due to some 
default or error of diet as yet unrecognized, or whether, like cholera, en- 
teric fever, or syphilis, it is imparted in some special way by the sick to 
the healthy, are matters in regard to which we have no accurate know- 
ledge. It may be added that certain recent statements in respect to the 
introduction of leprosy into the Sandwich Islands and into Australia, and 
its subsequent spread in those countries (assuming them to be correct), go 
far to establish its communicability. Dr. Liveing concludes that, if not 
contagious in the ordinary sense of the word, it is capable of propagation 
by the imbibition of the excreta of lepers. 

Symptoms and progress. — Leprosy is a disease of both sexes and all 
ages, but commences most commonly in early adult life. It is usually 
preceded by premonitory symptoms which continue for weeks, months, or 
even years, before the specific signs of the disease manifest themselves. 
These consist in the first instance in lassitude and depression, attended 
with more or less febrile disturbance, rigors, nausea, and loss of appetite. 
After a time livid blotches make their appearance here and there on the 
surface of the skin, remain out for a few days or a few weeks, and then 
subside, to be followed at irregular intervals by other similar outbreaks. 
They are tender, elevated disks, or rings, or more or less irregular patches, 
varying perhaps from half an inch to two or three inches in diameter. In 
the course of time the blotches become more persistent, and their subsi- 
dence is followed either by brownish pigmentary stains, or by an unnatural 
whiteness and opacity of the skin, associated with more or less contraction 
and depression. The central area of a patch not unfrequently assumes 
one or other of these conditions, while its periphery is still extending in 
the form of an elevated livid ring. During the earlier of these stages the 
affection has often some resemblance to psoriasis, lupus, or acne rosacea, 
and is sometimes termed macular leprosy ; during the later of them the 
condition of skin is sometimes designated morphcea nigra or alba, accord- 
ing as the cicatricial area is pigmented or colorless. 

The specific phenomena of leprosy now begin to develop themselves, 
and these vary according as the skin and mucous membranes on the one 
hand, or the nerves on the other, are principally affected. Many cases no 
doubt occur in which all of these tissues are implicated either simulta- 
neously or in succession; but in a large number the specific morbid pro- 
cesses are almost accurately limited to one or other tissue, and the disease 
hence assumes two distinct and easily recognized types. They are known 
as ' tubercular'' and ' anesthetic leprosy' respectively. 

In tubercular leprosy, which is relatively most common in temperate 
climates, nodular elevations slowly develop themselves in the substance of 
the cutis, and mainly on the site of the macular eruption. These are 
attached by broad bases, become more and more prominent and sometimes 
pedunculated, and not unfrequently coalesce with one another so as to 
form irregular nodulated masses. They vary at length individually from 
perhaps the size of a hazel-nut to that of a walnut. They are for the most 
part hard and resistant, of a dusky reddish or brownish hue, smooth and 
sometimes polished on the surface, and often, like those of lupus, present a 
certain degree of translucency. They are attended with little inherent 
pain or uneasiness, but are more or less tender, and are remarkable for 
their permanence and the little tendency w T hich they manifest to undergo 
degeneration or ulceration. Nevertheless they do occasionally, after a 
long time, become the seat of some partial fatty change, grow softer and 



260 



SPECIFIC FEBRILE DISEASES. 



almost fluctuating, and acquire a dirty yellowish hue ; and not unfrequently 
also, when irritated by exposure, filth or injury, they become excoriated 
or ulcerated, or covered with thin scabs, and exude a serous or ichorous 
fluid. The growth of the tumors is attended with atrophy of the cuta- 
neous glands and of the hair. The latter first becomes thin and dry and 
loses its color, and then disappears entirely. It is important, however, to 
note that the loss of hair is not, as in syphilis, general, but simply limited 
to the situations in which there is obvious disease. The tubercles of 
leprosy occur mainly on those surfaces which are most exposed to the air, 
namely the face, hands and feet, but they are common also on the extensor 
aspects of the limbs. On the face they chiefly affect the eyebrows and 
eyelids, the nose and lips, and the lobes of the ears. The nodulated 
thickening of the eyebrows and adjacent parts of the forehead gives a 
peculiar morose character to the expression ; and the thickening of the 
nose and lips with the associated bronzing of the parts imparts to the 
European the appearance of the mulatto. When the face is thus affected 
the term leontiasis is sometimes applied to the disease. In the hands and 
feet the back or dorsum is chiefly involved. In addition to the cutaneous 
growths which have just been described, nodules of the same kind appear 
in the subcutaneous tissue. The morbid process is limited to the skin and 
subjacent tissues for a longer or a shorter time ; but at length certain of 
the mucous membranes become implicated, especially those of the nose, 
mouth, and larynx. The affection here is of the same kind as that in the 
skin ; it consists in the formation of nodules which increase in size, run 
together, and sometimes form flattened elevations. The growths, however, 
are softer, more readily ulcerate, and on healing leave deep and dense 
cicatrices. In the progress of the disease the cartilages of the nose not 
unfrequently become exposed, the tongue large, nodulated, and seamed with 
cicatrices, and the different parts of the larynx thickened and stiff, and its 
channel contracted. In association with the affection of the larynx a 
peculiar cough and hoarseness of voice become developed which are very 
characteristic of the disease. According to Danielssen and Boeck the 
trachea and bronchial tubes may undergo the same changes as the larynx. 
The conjunctivae are apt to be similarly affected, and inflammation, sup- 
puration, and perforation of the corneas to ensue. 

In ancesthetic leprosy, which is specially common in hot climates, it not 
unfrequently happens that no tubercles are ever developed. And the cuta- 
neous affection may either be that which has been described as among the 
prodromal phenomena of leprosy, or it may be so slight that attention is 
first called to it by some impairment or change of sensibility. There may 
even be no structural change whatever. We will first consider the nervous 
phenomena, and afterwards the local processes going on in the skin and 
subjacent parts. In the first instance there may be a combination of 
hyperesthesia and anaesthesia, some parts being numb or insensible, while 
others burn or tingle and are excessively tender, and not unfrequently areae 
of numbness are surrounded by rings of increased sensibility; these con- 
ditions, moreover, replace one another, so that parts which were hyper- 
aesthetic become anaesthetic; and, further, they may occupy numerous 
scattered spots or pervade separately or in combination extensive tracts of 
skin. They are often connected, though by no means necessarily so, with 
the cutaneous maculae. The affection of the sensory nerves is generally 
associated with affection of the motor nerves, and indeed the latter 
(although it seems to come on later) occasionally preponderates. Thus, 



LEPROSY. 



261 



there are often tremblings and jerkings of the limbs ; but especially there 
soon supervenes muscular paralysis. The anaesthetic and paralyzed regions 
gradually shrink, the fat, the muscles, and even the bones waste, and the 
skin contracts over them, becoming white or pigmented, and assuming 
more or less of a cicatricial character. The parts which are generally 
first affected, and which suffer most severely are the hands and forearms, 
feet and legs — -in the upper extremity mainly those parts which are sup- 
plied by the ulnar nerve, and in the lower extremity the regions corre- 
spondingly situated on the outer side of the leg and foot. It will be 
recollected that the ulnar nerve, besides giving sensory branches to the 
inner side of the lower part of the arm, to the inner side of the hand, and 
to the ring and little fingers, supplies motor nerves to the flexor carpi 
ulnaris, the inner half of the flexor profundus, the muscles of the ball of 
the little finger, the interossei, the adductor muscles of the thumb, and 
the palmaris brevis. And the consequence of their wasting and loss of 
function is that the palm becomes flattened, the thumb separated from the 
other fingers, and these powerfully extended at their first joints, and flexed 
at their second and third joints — conditions which impart to the hand the 
well-known claw-like form which always results from paralysis of the 
ulnar nerves. Bullae not unfrequently form and burst, sometimes healing 
quickly and well, at other times leading to obstinate ulcers, which leave 
hard depressed cicatrices behind. After a time gangrene is apt to occur 
in the affected parts, more especially in the hands and feet. This some- 
times begins from the surface, and gradually deepens until the bones are 
exposed; sometimes begins among the deeper tissues, and involves the 
skin secondarily. Jt often ends in the separation of the bones, in the loss 
of fingers or toes, or even of a hand or foot. It is remarkable, however, 
how rapidly and perfectly wounds thus made heal up. 

The duration of leprosy is very uncertain; that of the anaesthetic variety 
is, on the average, sixteen or seventeen years, that of the tuberculated 
form eight or nine. Death is due partly to gradual impairment of nutri- 
tion, but mainly to the supervention of complications, especially phthisis, 
dysentery, and kidney affections. 

Morbid anatomy and pathology. — The morbid process on which the 
chief phenomena of leprosy depend consists in the infiltration of the 
affected tissues with innumerable small cells containing comparatively 
large nuclei. These, in accordance with Virchow's views, are probably 
due to proliferation of the connective tissue corpuscles; and collectively 
form more or less extensive masses of new growth which are almost iden- 
tical microscopically with granulation-tissue and with the tissue of syphi- 
litic gummata, or of lupus. The leprous growth differs, however, from 
the latter two especially, by its permanence and comparatively little ten- 
dency to undergo degenerative changes. The new growths present, at all 
events during their earlier progress, a grayish, yellowish, or brownish 
tint, are firm, translucent, and homogeneous in texture, and contain few 
bloodvessels and little blood. 

In tubercular leprosy the tumors commence in the skin around the hair 
follicles and glands, which in their progress they gradually compress and 
destroy, together with the majority of the other textures which they in- 
volve; the epidermis, however, remains for the most part normal, and the 
muscles of the hairs, in the beginning at all events, become hypertrophied. 
The tubercles do not usually admit of being enucleated, but are connected 
by processes with the subcutaneous connective tissue. Their formation 



262 



SPECIFIC FEBRILE DISEASES. 



beneath the skin and in connection with the mucous membranes essen- 
tially accords with the above description. It must be added that both in 
the macular stage and in the anaesthetic form, the cutis, however slightly 
it may appear to be affected, is still the seat of specific proliferation. 

In anaesthetic leprosy the nerves are always implicated to a greater or 
less extent — the smaller branches being mainly involved, and of the nerve 
trunks those portions which are most superficial and most obnoxious to 
injury. They swell to several times their normal bulk, sometimes uni- 
formly, but more frequently irregularly, so as to present something of a 
beaded character. They become at the same time firm, grayish, and 
translucent. The change is due to a proliferation of the cells of the con- 
nective tissue of the nerve-bundles (mainly of that which separates the 
individual nerves from one another, and of that which bounds and isolates 
their different strands), and exactly resembles what occurs in the skin and 
mucous membranes. At first the essential elements of the nerves suffer 
but little from the adventitious growth which surrounds them ; eventually, 
however, they undergo degeneration. 

Dr. Vandyke Carter 1 shows that, in anaesthetic leprosy, the affected 
muscles become converted into fibrous tissue ; and that the bones especially 
of the hands and feet waste ; that the carpal and tarsal bones suffer thus 
to some extent, but that the metacarpal, metatarsal, and phalangeal bones 
are chiefly affected, and in an increasing, order from the first of these to 
the last phalanges ; that their shafts become attenuated, and their distal 
extremities disappear. He shows also that these conditions involve mainly 
the fourth and fifth fingers and the corresponding toes, and that here the 
last phalanx not unfrequently disappears wholly, the skin and nail then 
shrinking on to the top of the second phalanx. 

We have already adverted to the statement of Danielssen and Boeck 
that leprous patients are liable to the development of specific tubercles 
throughout the bronchial tubes ; they describe them also as occurring in 
the substance of the lungs, liver, and other organs. These statements 
have not, however, been fully verified by subsequent observers. It is 
certain, however, that in all forms of leprosy the lymphatic glands become 
largely hypertrophied, and mainly those which are in immediate connec- 
tion with diseased districts — the glands which chiefly suffer being those 
of the groin and those of the neck and submaxillary regions. Distinct 
leprous infiltration and degeneration of the testicles is recorded by Virchow. 

The ulceration, gangrene and other inflammatory processes, which are 
so common in the course of leprosy, seem to be due, not so much to any 
special tendency which leprous formations have to pass into such condi- 
tions, as to what may be regarded as accidental circumstances. Thus in 
the case of tubercular leprosy, ulceration seems to result from the effects 
of exposure, cold, dirt, and other sources of irritation ; and, in the case 
of anaesthetic leprosy, the ulceration and gangrene are probably mainly 
dependent on the irritative implication of the nerves. 

Treatment — By common consent leprosy is an incurable disease ; nor 
does it admit of alleviation or arrest by medicinal treatment ; but it is 
doubtless well, when the case admits of it, to remove the patient from a 
locality in which the disease is endemic, to protect his surface as far as 
possible from injurious influences of all kinds, and to maintain his strength 
by appropriate food and various tonic adjuvants. 



1 On Leprosy and Elephantiasis, 1874. 



AGUE. 



263 



XXV. AGUE. {Intermittent and Remittent Fever.) 

Definition A specific non-contagious fever, produced by malaria ; 

characterized by enlargement of the spleen and recurring attacks of fever 
attended each with a cold, a hot, and a sweating stage ; and having an 
indefinite duration, and a tendency to recur, which may last for many years 
or during the whole of life. 

Causation and history Ague is undoubtedly not contagious. It is 

not communicable from man to man, nor does it spread from a centre, 
successively invading town after town and country after country. It is 
strictly an endemic affection, belonging to certain districts and induced in 
them by some poisonous influence which pervades them. Ague districts 
are scattered more or less irregularly over the whole non-aqueous surface of 
the globe, excepting apparently that of the frigid zone. And the virulence 
of the poison which they yield increases for the most part as they approach 
the equator. They generally present certain common features : they are 
tracts of low-lying marshy ground, often situated upon rivers or lakes or 
in the vicinity of the sea, often presenting a luxuriant vegetation, and 
always a porous soil which is commonly composed to a large extent of 
decaying vegetable matter. But, however fever-stricken such places may 
be, the malaria which they breed is evolved at certain seasons only. In 
our own country, and probably in all temperate climates, the dangerous 
periods are spring and autumn, especially autumn ; in the tropics, the 
season of heat and drought which follows upon the periodical rains ; and 
in all cases, it would seem that the poison is produced only or with special 
intensity, not when the marshy ground is thoroughly soaked, but when, 
after it has been thus soaked, the surface to a little depth has undergone 
a rapid process of drying. What, it may be asked, is the condition com- 
mon to all the variously situated aguish regions which causes ague? Is 
it high temperature ? Clearly not : for many of the hottest regions of 
the earth are completely blameless. Is it the presence of water? The 
answer must be No ; for, if aqueous vapor could cause ague, all who fre- 
quent the sea, or live in the vicinity of rivers, should contract ague ; and 
especially, aguish districts should be most dangerous at those very times 
when they are now most free. Is it the presence of decaying vegetable 
matter? Again the answer must be No. Decaying vegetable matter 
exists abundantly in places where ague never occurs ; and moreover, as 
Sir Thomas Watson remarks, if such matter could cause ague, Londoners 
ought at least to be occasionally infected by the contents of their dust-bins 
and by the neighborhood of Covent Garden market. But the specific in- 
fluence of decaying vegetables in the causation of ague is disproved by 
the fact that ague prevails in certain places where no such matter exists. 
' In August, 1794, after a very hot and dry summer, our army in Holland 
encamped at Rosendaal and Oosterhout. The soil in both places was a 
level plain of sand, with a perfectly dry surface, where no vegetation ex- 
isted, or could exist, save stunted heath plants. It was universally perco- 
lated to within a few inches of the surface with water, which, so far from 
being putrid, was perfectly potable. Here fevers of the intermittent and 
remittent type appeared among the troops in great abundance.' (Watson.) 
Again, the soil of Hong Kong consists of disintegrated granite, contain- 
ing, according to Dr. Parkes, less than 2 per cent, of organic matter, yet 
ague, which had not previously prevailed, became rife and fatal at a time 



264 



SPECIFIC FEBRILE DISEASES. 



when the soil was being extensively excavated for building purposes. The 
last quotation illustrates another point of considerable importance in rela- 
tion to the causation of ague, namely, the influence in this respect of 
upturning of the soil, of soil at any rate which has long been untouched. 
The malarious affections which prevailed in the armies before Sebastopol 
are referred by Trousseau to this cause ; and he also points out that in 
Paris, where ague is almost unknown, epidemics of limited duration have 
on several occasions been distinctly traced to the formation of extensive 
excavations. 

It would seem, therefore, that neither heat, water, nor decomposing 
organic matter is alone capable of evolving the malarious poison ; but that 
for its production there must be a certain porous character of soil, a certain 
degree of saturation of this soil with water — the surface having recently 
undergone desiccation — and a certain elevation of temperature. It may 
be added that nothing is more certain than that aguish districts may be 
rendered perfectly healthy by drainage. In London, most of which is 
built on land which was formerly marshy, and where ague was once largely 
prevalent, the disease is now rarely if ever met with unless it be imported. 

The malarious poison appears to be manufactured in the soil of the 
malarious district, and to be exhaled from the surface in company with 
the moisture which rises from it, and at night-time far more abundantly 
than in the day. It forms over the infective area a kind of invisible mist, 
which is denser and more potent in proportion to its proximity to the 
ground, and which extends to no great height above it. Indeed, it is well 
known that the ground- floors of houses in aguish districts are more danger- 
ous to sleep in than are the higher stories ; and that the miasm rarely 
ascends to any great height the sides of mountains which adjoin such 
districts. Dr. Parkes considers that the upward limit in temperate climates 
is 500 feet, in tropical climates from 1000 to 1500 feet. As might be 
supposed, the miasm may be carried by the wind and atmospheric currents 
beyond the limits of the area in which it is produced ; and thus, under 
certain circumstances, places which are miles away, and in all other respects 
healthy, not unfrequently become affected. It seems, however, that the 
miasm is absorbed in its passage across water, so that the intervention of 
a river three-quarters of a mile or a mile broad, or of a similar breadth of 
sea, gives perfect safety. Even a belt of trees, acting probably as a kind 
of filter, will often form an efficient barrier. For the latter reason it is 
especially dangerous to sleep under trees in malarious places. It is also 
dangerous, according to some, to drink the water, however pure it may 
seem to be, which is furnished by the soil of such localities. 

What, then, is this miasm ? Is it a gas, is it some decomposing organic 
substance, is it a living thing? No direct proof has yet been adduced of 
the truth of either of these alternatives. There is, however, much, both 
in the behavior of the miasm and in its effects on the human body, to 
indicate a generic relationship with the contagia of infectious fevers, and 
to render it probable, therefore, that the last of the alternatives above ex- 
pressed is entitled to acceptance. Dr. Salisbury, of Cleveland, indeed, 
believes that he has discovered the specific cause in the sporules of certain 
algae, species of palmellae. 

There are certain facts in reference to the causation of ague, besides 
those which have been considered, to which attention should be drawn. 
It seems to be well ascertained that the denizens of malarious districts tend 
to become, in a greater or less degree, acclimatized, and that hence they 



AGUE. 



265 



less readily contract ague than persons newly arrived. It is remarkable 
how little the negroes suffer in districts which are fatal to Europeans. 
Another well-ascertained fact is that persons suffering from fatigue or pri- 
vation are much more liable to take the disease than those who are well- 
fed, strong, and in robust health. Again, contrary to all we know of most 
other fevers, especially of the exanthemata, one attack of ague, so far from 
being protective, renders its subject more than ever liable to be attacked 
with it on exposure to its exciting cause. 

Symptoms and 'progress. — The period of latency of miasmatic affections 
varies within wide limits. Authentic cases are recorded in which persons 
who have been exposed to the paludal poison have manifested the first 
symptoms of fever within the ensuing four-and-twenty hours. On the 
other hand, it by no means unfrequently happens that persons who have 
been residing in aguish districts at the time of year when ague chiefly 
prevails have their first attack of ague many months after they have re- 
moved thence to some perfectly salubrious locality. Thus we frequently 
meet with persons, residing in healthy parts of London, who are attacked 
during the spring or summer with symptoms of ague, the poison of which 
was taken into the system during the previous autumn, in Essex or Kent, 
and had lain dormant during the whole of the intermediate period. 

Ague presents itself clinically in two well-marked extreme forms, which, 
however, pass one into the other by insensible gradations. The first of 
these is the intermittent fever, which is especially common in temperate 
climates, and comparatively mild ; the second is the remittent fever, which 
occurs chiefly in the tropics, and is of great severity and danger. We 
will describe first the phenomena of intermittent, and then those of remit- 
tent fever. 

A. Intermittent fever is characterized by the occurrence of febrile attacks 
of some hours' duration, separated from one another by periods of appa- 
rently, or at all events, comparatively good health. The patient is attacked 
suddenly, or after having complained for some indefinite time of lassitude, 
headache, and general malaise, with a sense of chilliness, and weariness, 
headache, muscular pains, and epigastric discomfort. The chilliness 
rapidly increases until the patient feels and looks as if he were suffering 
from intense cold. He begins to shiver — the sensation of shivering com- 
mencing in the back and extending thence to the rest of the body. The 
shivering is speedily converted into a severe rigor, attended with violent 
chattering of the teeth and convulsive tremblings of the trunk and limbs. 
At the same time the skin is dry, and assumes the papular condition known 
as ' goose's skin ;' the face and the hands and feet acquire a dusky hue, 
the face also looking pinched, the hands and feet shrunken and wrinkled. 
Whilst this condition lasts the pulse is small, frequent, and often irregular; 
the respirations are quick and sighing; there is loss of appetite, thirst, and 
epigastric oppression, not unfrequently associated with sickness ; the tongue 
is perhaps bluish, and slightly furred ; headache and pains in the back 
and limbs are often present, and sometimes torpor or drowsiness ; and the 
urine is pale, abundant, and passed frequently. The length of this, which 
is termed the ' cold stage,' presents great variety. In some cases it is 
represented by a slight sensation of chilliness of a few minutes' duration 
only. It more commonly lasts from half an hour to one or two hours, and 
is occasionally prolonged to three or four hours, or even more. During 
the whole of this stage the temperature of the patient is above the normal, 
and rises rapidly. The elevation begins in fact before the patient himself 



266 



SPECIFIC FEBRILE DISEASES. 



recognizes the commencement of his attack, and rises quickly and uni- 
formly until towards the close of the stage ; at which time, even though 
he be still trembling violently with the feeling of intense cold, the thermo- 
meter placed in his axilla probably marks 105°, 106°, or even 106.3°. 

After a time the cold stage subsides, and the next, the hot stage com- 
mences. The rigors and aspect of chilliness gradually disappear — slight 
flushes at first alternating with the diminishing rigors, and then by degrees 
replacing them. The patient begins to feel comfortably warm, and the 
shrunken and livid surface assumes the smoothness and hue of health. 
But gradually the feeling of heat gets intense ; the patient looks excited 
and flushed ; the skin feels dry, harsh, and pungently hot; the pulse be- 
comes fuller, stronger, and soft, but maintains its frequency ; the respira- 
tions get more rapid and deeper, and the thirst more severe ; anorexia 
continues ; the urine is still abundant, but of a darker color and higher 
specific gravity ; and the headache, which differs in character from that 
previously complained of, becomes extreme ; mental confusion is not un- 
common, and occasionally there is slight delirium. During this stage the 
temperature continues high ; sometimes during the early part attaining a 
higher elevation than was reached during the cold stage, sometimes, on the 
other hand, falling somewhat below it. The hot stage lasts from one or 
two hours up to four or five, but is occasionally prolonged to eight or ten 
hours. 

The hot stage is succeeded by the third, or sweating stage. The ap- 
proach of this is indicated by the supervention of a general feeling of com- 
parative comfort ; the intense heat of skin diminishes somewhat, and 
moisture appears on the face, and rapidly involves the whole surface of the 
body ; soon the patient is bathed in profuse sweats ; the temperature 
rapidly falls ; the pulse becomes less frequent and softer ; the respirations 
resume their normal rate ; the headache disappears ; the loss of appetite 
and the thirst abate ; the urine gets scanty, but of variable color, and 
deposits a sediment on cooling ; and not unfrequently the patient falls into 
a gentle sleep. The duration of this stage is very various, but is gene- 
rally shorter than either of the other two. On emerging from it, the 
patient may still be languid and listless, but on the whole appears to be 
restored to more or less perfect health. 

The duration of the febrile paroxysms and that of their different stages 
present considerable variety. The whole paroxysm may be completed in 
an hour or two, or may be prolonged to eight or ten, or even twelve hours. 
The cold stage, as has been pointed out, may last from a few minutes to 
some hours, and not unfrequently the shorter cold stage is followed by the 
longer and more intense hot stage. Again, the hot stage, which is often 
of some hours' duration, is occasionally absent — the sweating stage in such 
cases following immediately upon the cold stage. And lastly, the sweat- 
ing stage may be so slight as almost to escape notice, or may be protracted 
for many hours. 

The period which intervenes between the cessation of one attack and 
the commencement of the attack next following is called the ' intermission.'' 
In it the patient seems not unfrequently to be in the best of health. Some- 
times, however, he suffers from more or less malaise, the degree and char- 
acter of which depend on various circumstances which need not be specially 
considered. 

The period which elapses between the commencement of one attack and 
that of the attack which is next in sequence is termed the interval.'' And 



AGUE. 



267 



it is mainly in accordance with the length of this interval that we deter- 
mine the different varieties of ague. In one variety the interval is twenty- 
four hours, or thereabouts, and there is consequently a daily febrile parox- 
ysm. This is termed 4 quotidian ague.' In another variety the interval 
is forty-eight hours, more or less, and the paroxysm occurs every other 
day. This should strictly be called ' secundan ague ;' but those who 
framed its name chose to reckon the day of the first attack as one day, the 
day of freedom as another day, and the day of the next attack as the third 
day, and consequently attached to it the inaccurate, but now well-known 
name of 'tertian ague.' In another variety the febrile paroxysms occur 
every third day ; and this, which should strictly be named tertian ague, 
has received the designation of ' quartan ague.' In addition to these three 
principal varieties, others which are much rarer are occasionally met with. 
Thus, in some cases the fits recur every fourth, fifth, or even sixth day. 
And in some cases we have what are termed ' double tertians' or ' double- 
quartans. ' In the double tertian the patient has febrile paroxysms occur- 
ring every day ; but, while those of the odd days correspond with one 
another, in time of commencement, duration, and probably also other fea- 
tures, those of the even days, though presenting a like agreement among 
themselves, differ markedly from those of the other series. In the double 
quartan the patient suffers, as it were, from two series of quartan attacks, 
the first series of similar paroxysms occurring, say on the first, fourth, and 
seventh days ; the second series recurring on the second, fifth, and eighth, 
days. 

In quotidian ague the febrile paroxysm usually commences earlier and 
lasts longer than in either of the other common varieties — often persisting 
for ten or twelve hours. In the tertian variety its duration is usually six 
or eight hours ; in the quartan four or six. On the other hand, the cold 
stage is shortest in quotidian, longest in quartan ague. The interval, as 
has been pointed out, is rarely exactly twenty-four, forty-eight, or seventy- 
two hours ; when it falls short of either of these periods each successive 
febrile attack commences earlier in the day than that which immediately 
preceded it, and is said to anticipate ; when the interval is prolonged, the 
periodical paroxysms become later and later, and are said to postpone. In 
the former case the disease is generally becoming more severe ; in the 
latter case there is usually a tendency towards improvement. Tertian 
ague is at any rate in Europe more common than either of the other 
varieties ; none of them, however, is rare, and they readily and not unfre- 
quently pass the one into the other. 

B. Remittent fever — the form of ague most common in tropical climates — 
is much more serious and dangerous to life than the intermittent forms of 
ague which have just been considered. Its distinguishing feature is that 
the febrile paroxysms, which come on once or twice a day, are not sepa- 
rated from one another by intermissions of complete apyrexia, but are 
rather to be regarded as exacerbations of an abiding febrile state. Further, 
the cold stage of each exacerbation is always of short duration, sometimes 
indicated by a few minutes only of shivering or chilliness, and sometimes 
escaping recognition ; the hot stage is much prolonged, lasting from six to 
twelve hours ; and the sweating stage is imperfectly developed, and merges 
into the period of remission from which it is undistinguishable. The 
attack of remittent fever is sometimes sudden, but is more commonly pre- 
ceded by premonitory symptoms, such as chilliness, lassitude, loss of appe- 
tite, nausea, epigastric uneasiness, and pains in the head and limbs. The 



268 



SPECIFIC FEBRILE DISEASES. 



actual febrile paroxysm begins with a rigor or slight chilliness, to which 
the hot stage speedily succeeds, and after some hours ends in perspiration 
and the period of remission — the remission, like the hot stage, varying in 
length from two or three to twelve hours. The paroxysms usually increase 
in intensity day by day for a few days. The symptoms which the patient 
presents are for the most part like those which attend intermittent fever, 
but some of them are much more severe. The temperature attains no 
greater height, but it never falls during the remissions to the normal 
standard ; there is no difference as regards the respirations and pulse, 
except perhaps that the latter with the progress of the disease tends to 
become quicker and weaker. Sickness is much more severe during the 
hot stage of remittent fever than in the corresponding period of intermittent 
fever, is often very distressing, and sometimes attended with hasmatemesis 
(black vomit) ; the tongue is drier, and occasionally there is slight, jaun- 
dice; headache and pains in the limbs are more intense; confusion of 
intellect is more common, and drowsiness, delirium, and coma are not 
unfrequent. The patient often passes into a distinct typhoid condition, 
with dry brown tongue, sordes on teeth, muttering delirium, subsultus ten- 
dinum, and other symptoms of the kind. 

Remittent fever presents at first sight an almost closer relationship, in 
the type of its fever, with enteric fever and hectic (which usually also are 
distinctly remittent), than with the varieties of intermittent fever. And 
indeed enteric fever and hectic were formerly, in many of their forms, 
termed remittent, and regarded as of malarious origin. It is certain, 
however, that the so-called remittent fevers of temperate climates have no 
affinity with ague. And, on the other hand, it is equally certain that 
there is no essential difference between the remittent and intermittent 
forms of ague. For not only do they arise from the operation of the same 
miasm, and present symptoms essentially alike, but their varieties shade 
into one another by insensible gradations, and they alternate with one 
another or replace one another in the same individual. 

The effects of the ague-poison are not always in accordance with the 
above description ; thus there are described some cases in which the 
paroxysm consists in a violent and prolonged cold stage only, during which 
the temperature is actually lowered — the patient suffering from extreme 
anxiety and intense thirst, and looking like a corpse ; or in which, inde- 
pendently of any other peculiarity, he falls into a condition of exhaustion, 
and lies torpid, motionless, and as if asleep, for many hours ; others, in 
which the sweating comes on early, is exceedingly profuse and of long 
duration, and during which the temperature falls rapidly, and the patient 
lies in a condition of extreme collapse ; others, in which the patient pre- 
sents coma or delirium, or has epileptiform or tetanoid convulsions coming 
on in the cold or hot stage, and continuing until the establishment of the 
sweating stage ; and again others, in which hemorrhage takes place from 
the nose, stomach, bowels, bladder, or into the substance of organs. [Parox- 
ysms of this character sometimes occur in the course of an attack of 
intermittent or remittent fever of apparently mild type, or abruptly usher 
in the seizure. They are frequently of such violence as seriously to en- 
danger life. Indeed death has occasionally resulted from a single paroxysm, 
but it is more usual for this to be postponed until after the second or third. 
In some cases in which the paroxysm is attended with excessive vomit- 
ing and purging, the symptoms are so urgent and inexplicable as to 



AGUE. 



269 



give rise to the opinion that they are due to corrosive poisoning. It is 
said that warning is sometimes given of the approach of these paroxysms 
either by a gradually increasing severity of the previous paroxysms, or 
by some irregularity in their development ; so that their occurrence may 
be often prevented by appropriate treatment. Generally, however, this 
warning is either absent, or if present, is overlooked. Although they are 
met with most frequently in the southern and southwestern districts of the 
United States, they are occasionally observed as far north as the Middle 
States. In consequence of their extreme fatality, the term pernicious 
fever has been applied by some authors to the attacks in which they occur. 
As they are generally attended by congestion of some important organ, 
others have preferred to call them congestive fevers.] Further, there are 
various neuroses which are distinctly forms of ague, the more important 
of them being neuralgic affections of one or other of the branches of the 
fifth pair. That involving the supra-orbital constitutes one form of the 
malady known as ' brow-ague.' These may be recognized as being mala- 
rious, partly by their periodic character, partly by their occasional super- 
vention on a more or less distinct cold stage, partly by their occurrence in 
a malarious district, partly by the fact that the patient has already been 
the subject of ague. 

There are one or two points in reference to the paroxysms of ague to 
which we have hitherto only very briefly alluded, but which are neverthe- 
less of considerable importance. In intermittent fever, during the cold 
and hot stages the urine is usually secreted in considerable abundance, is 
pale and of low specific gravity, and the patient generally has very fre- 
quent desire to micturate. He passes an excess of urea, uric acid, and 
chloride of sodium, while phosphoric acid is diminished. During the 
sweating stage the urine becomes scanty and darker colored, and the 
amount of the excreted solids which was previously in excess undergoes 
diminution. In the intermission urea and uric acid fall below the normal 
standard. In the remittent form of ague the same peculiarities exist, but 
are necessarily somewhat less marked. In both forms there is occasionally 
albuminuria or hematuria, with renal casts. The spleen is invariably 
enlarged during the paroxysms, becomes especially swollen during the cold 
stage, and may generally be easily recognized by palpation or percussion ; 
it then subsides, and during the intermission may return to its normal 
bulk. If, however, the ague persists, the splenic enlargement becomes 
more or less permanent. 

The duration of ague presents great differences. An attack will proba- 
bly always subside (unless death supervenes) after some indeterminate 
period ; especially it will subside if the patient be removed from the dis- 
trict in which he contracted it. But this subsidence is rarely final. In 
the great majority of cases the patient remains for months or years, or for 
his lifetime, liable to fresh attacks of ague, even if he never again ven- 
tures into a malarious district. The attacks then recur at irregular inter- 
vals, and are generally determined by some accidental circumstance, such 
as over-fatigue, an attack of catarrh or indigestion, or the supervention of 
other ailments, whether mild or serious. In other words, the malarious 
poison becomes a portion of his being, and seems to tinge and qualify any 
morbid condition which happens to arise. Death from the ordinary inter- 
mittent fevers is very rare ; but remittent fever, unless it be promptly 
treated, is a very fatal disease. The patient dies for the most part in the 



210 



SPECIFIC FEBRILE DISEASES. 



typhoid condition, and rarely (according to Dr. Maclean) before the eighth 
day. 

If ague assumes a chronic form, and especially if the patient has been 
long resident in an aguish climate, or has had periodical attacks for many 
years, organic changes take place in the liver and spleen ; their functions 
become impaired or perverted, and chronic conditions of disease are sooner 
or later developed. Among the more important of these are various forms 
of cachexia and dropsy. In some cases the patients simply pass into a 
condition of debility and anaemia, on which general dropsy may supervene 
after a time ; in some cases jaundice becomes associated with this anaemia, 
and from the same affection of the liver as causes this, ascites or haemate- 
mesis and mekena may eventually come on ; in some cases, again, degen- 
eration of blood-corpuscles takes place in the spleen, and their conversion 
there into brown or black pigment-granules, and the diffusion of this pig- 
ment thence throughout the system, give a peculiar dirty or bronzed hue 
to the complexion. Some degree of such discoloration indeed is of com- 
mon occurrence in persons who have had repeated attacks of ague. 

It may be added that it is not uncommon for the denizens of malarious 
regions to become the subjects of the visceral lesions and cachexias which 
supervene on ague without ever having experienced a distinct attack of 
ague — the malarious poison appearing to affect the system slowly and in- 
sidiously, and without even the warning which an occasional febrile par- 
oxysm might afford. 

Morbid anatomy and pathology The pathology of ague is very obscure ; 

and morbid anatomy throws little light upon it. We know that a poison 
(probably living) is taken into the system, and that this remains incor- 
porated with it for an indefinite period, giving rise at irregular intervals 
to more or less distinctly periodical attacks of well-marked fever, attended 
with rapid destruction of tissue, high temperature, and congestion of in- 
ternal organs, but more especially of the spleen. But where the poison 
lurks, why it acts periodically, and on what organ or organs it acts chiefly, 
are matters concerning which we do not positively know anything. There 
is, however, good reason to believe, on the one hand, that it is not dis- 
charged from any surface, and on the other that (whether it acts directly 
or indirectly thereon) its main effects are wrought through the agency of 
the sympathetic system of nerves. It is scarcely probable that the enlarge- 
ment of the spleen and associated changes in the liver, important though 
they be in many respects, are anything more than secondary phenomena. 
The only constant lesion discoverable after death is enlargement of the 
spleen. This organ becomes distended with blood, and often to many 
times its normal size ; and if the patient die when the attack of ague is 
recent, it is found large and congested. The liver, too, is commonly to 
some extent engorged and increased in bulk. [The liver, in addition to 
the changes noted above, is often very much softened and altered in 
appearance. According to Dr. Stewardson its color is a mixture of gray 
and olive, the natural reddish-brown being entirely extinct or only faintly 
to be traced. This alteration is found uniformly distributed, or nearly so, 
throughout the whole extent of the organ. The glands of Brunner in the 
duodenum are occasionally enlarged, but probably no pathological import- 
ance ought to be attached to this lesion or to the gastritis which is also 
sometimes met with.] Congestion of the neighboring parts of the alimen- 
tary canal has also been observed ; and it may be added that in hemor- 



AGUE. 



2U 



rhagic cases traces of hemorrhage at mucous surfaces and beneath the 
serous membranes may be discovered. 

Enlargement and induration of the spleen and liver are among the com- 
mon results of long-continued or repeated attacks of ague, or of long resi- 
dence in malarious districts. Another change to which these organs are 
liable is a peculiar dark or slaty discoloration, due to disintegration of 
blood corpuscles and their conversion into pigment-granules. In the liver 
this is generally referable to the changes which occur in minute extrava- 
sations of blood into the capsule of Glisson and the hepatic parenchyma; 
in the spleen, to similar changes going on in the blood which occupies the 
intermediate blood-passages. The pigment is apt to escape from the 
spleen, to enter the general circulation, and to become arrested in the 
capillaries of different organs, more especially the liver, brain, and kid- 
neys, and thus not only causes them to be pigmented, but interferes more 
or less with their nutrition, and induces various organic changes and func- 
tional disturbances. 

Treatment What the prophylactic treatment of ague should be may 

be surmised from the foregoing account of the disease. 1st, when prac- 
ticable, malarious districts should be thoroughly drained and cleared of 
underwood or jungle; 2d, those w r ho are compelled to remain in them 
should take ample precautions ; should not go out in the evening, the 
night, or the early morning ; should ' sleep in the higher rooms of the 
houses they occupy ; should not drink the water of the locality unless it 
be well filtered or boiled; especially should not expose themselves to the 
malarious influences when they are ill or fatigued ; and on going out 
should, as Sir T. Watson suggests, wear charcoal respirators, and also 
regularly take such remedies as are efficacious in curing ague ; and, 3d, 
persons who are actually attacked w 7 ith the disease should be removed to 
some healthy locality. 

In treating ague medicinally we have to consider, first, the treatment of 
the paroxysms, and next that of the disease. It is reasonable to suppose 
that the ague patient will experience some actual benefit if we assuage 
some of his discomforts, and hence that he will be benefited, during the 
cold stage by the application of warmth, either by packing, w r arm bottles, 
hot-air baths, or warm-water baths ; during the hot stage by the mainten- 
ance of a cool atmosphere, by the use of light clothing, and by tepid or 
cold sponging; and, during both, by the administration of diluents. Little 
or nothing, in fact, is necessary beyond such simple measures. Other 
remedies, however, have been employed, and some reputedly with consider- 
able success. Thus, emetics have sometimes been given previous to the 
fit; and bleeding has been much lauded as a means of relief during the 
cold stage. The most valuable, however, of such special modes of treat- 
ment seems to be the exhibition of opium in largish doses (about thirty 
minims of the tincture) during the cold or hot stage. 

It is of infinitely greater importance to attack the disease itself, and for- 
tunately ague is one of those maladies for which we have almost unfailing 
remedies. Cinchona, indeed, its alkaloids, and arsenic are true specifics. 
There is no difference of opinion as to their efficacy ; the only difference 
which can exist is as to the mode of their administration and the dose. Of 
the several cinchona alkaloids, quinine, in the form of the sulphate, is un- 
doubtedly the most efficacious, and it is certainly much more convenient 
of administration than cinchona itself. There are two principal modes in 
which quinine is administered; by some physicians it is given in a single 



272 



SPECIFIC FEBRILE DISEASES. 



large dose before each paroxysm is expected, by others in smaller doses at 
comparatively short intervals. 

According to the former mode from twenty to thirty grains of quinine 
may be given for a dose to an adult. The time of its administration here, 
however, becomes important. By some it is thought best to give it just 
before the paroxysm, by others just after it and even during the sweating 
stage. The immediate object being prevention, it certainly seems most 
reasonable that the quinine should be given so long before the expected 
occurrence of the paroxysm as to allow of its being fully absorbed into the 
system; and hence, of these two alternatives, the latter should be pre- 
ferred. The plan, indeed, of giving the larger dose during the sweating 
stage can scarcely be improved upon either in the case of remittent or in 
that of quotidian ague. When, however, the paroxysms are separated by 
longer intervals, it is probably best either to divide -the large dose into two 
smaller doses and to give them at intervals, or to give the full dose between 
six and twelve hours previously to the expected attack. 

The other method, which is frequently pursued, is that of giving the 
quinine in smaller doses — three, four, or five grains — three or four times 
a day without reference to the times of occurrence of the paroxysms; and, 
indeed, it may be given freely even while a paroxysm is in progress. In 
some cases, owing to extreme irritability of the stomach, the quinine (in 
proportionately increased doses) must be given in the form of enema, or 
(in proportionately diminished doses) by subcutaneous injection. The 
time during which the administration of the remedy should be persisted 
in must necessarily vary with the case. It should be given for at least a 
week or two after all symptoms have disappeared ; and should be at once 
renewed if a tendency to recurrence manifests itself. It is important, 
however, to observe that quinine (and the same is true of arsenic) does 
not, by continuous use, even for many months, necessarily eradicate the 
disease. Arsenic is equally efficacious with quinine in the treatment of 
ague, and indeed sometimes effects a cure when quinine has failed. The 
liquor arsenicalis may be given in doses of from five to ten minims three 
or four times a day. 

[The treatment in the pernicious form of the disease must be prompt 
and energetic to be of any avail. During the paroxysms this will of course 
vary with the nature of the symptoms. In those cases characterized by 
extreme coldness and collapse — the algid type of some authors — it will 
frequently be necessary to have recourse to diffusible stimulants to save 
life. It is said that the cold douche has also been of service in this con- 
dition. In those accompanied by vomiting and purging, opium should be 
freely given, to which astringents may be added if there should be at the 
same time hemorrhage from the stomach or bowels. But necessary as it 
is to meet the indications presented by the paroxysm itself, it is of in- 
finitely more importance to prevent its recurrence. Therefore, as soon 
as the symptoms have somewhat subsided, and the stomach is sufficiently 
retentive, a full dose of quinia should be given and repeated until the 
patient is fully cinchonized. In many cases it will be necessary to give 
as much as forty or sixty grains before this is brought about. Experi- 
ence has shown that much more harm is likely to result from giving in- 
sufficient quantities of the drug than from pushing its administration to 
this point. Where it is persistently rejected by the stomach, it may be 
given hypodermically or by the rectum.] 

It may be well to observe that it is generally considered advantageous 



AGUE. 



273 



to keep the bowels freely open, and that indeed (so at least it is asserted) 
quinine and arsenic seem occasionally to be quite inefficacious until a 
purgative has been administered ; that the complications and sequelae of 
ague must be treated according to their nature; and that the diet (in regard 
to which no special rules need be laid down) must be regulated according 
to the condition, and the tastes or desires, of the patients. 

[The term typho-malarial fever, originally proposed by Dr. J. J. Wood- 
ward, of the U.S. Army, has been applied to the compound forms of fever 
which result from the combined influences of the causes of malarious fevers 
and of typhoid fever, and which not infrequently occur in the malarious 
regions of the United States as well as of other countries. Although this 
modification of typhoid fever did not escape the observation of Drake and 
Wood, it does not seem to have been fully recognized by the profession 
generally until after the outbreak of the late civil war, when it excited great 
interest under the name of Chickahominy fever. The symptoms are of 
course a combination of those presented by the two diseases when occurring 
separately, and vary in intensity and character as the cause of one or other 
of these diseases predominates. It is, therefore, not necessary to repeat 
them in detail. It is sufficient to say that if in the course of an attack pre- 
senting the phenomena of remittent fever, tympanites, tenderness and 
gurgling in the right iliac fossa, diarrhoea, and rose-colored spots occur, 
the case can no longer be regarded as one of uncomplicated malarial dis- 
ease. After death with the usual lesions of remittent fever those of typhoid 
will also be found. It is said by some writers that perforation of the in- 
testine is peculiarly likely to be met with in this variety of fever, but this 
is a statement which needs confirmation. 

In treating this combination of diseases it must not be forgotten that the 
recurrence of the exacerbations in remittent fever cannot but exercise an 
unfavorable influence upon the course of the typhoid fever. Full ante- 
periodic doses of quinia should therefore be administered just as in uncom- 
plicated malarial disease. All other indications will generally be appro- 
priately met by the treatment recommended in the chapter -on enteric 
fever.] 



18 



274 



DISEASES OF THE SKIN. 



CHAPTEE II. 

DISEASES OF THE SKIN. 

I. INTRODUCTORY REMARKS. 

Morbid conditions of the skin are of great interest and importance, 
partly because they are very common, partly because they are in many 
cases a valuable aid to us in the determination of the nature of internal 
maladies, partly because their presence so largely affects, not only the 
health, but the comfort and happiness of those who suffer from them. 
Further, their position renders them comparatively easy of observation. 
For all these reasons they have been repeatedly investigated and described 
with extreme care, and have been distinguished with a degree of minute- 
ness, and classified with an amount of ingenuity, which have been sur- 
passed only in the distinction and classification of the members of the 
vegetable kingdom. The result has undoubtedly been largely to increase 
the range and exactness of our knowledge of skin diseases ; but it may be 
questioned whether this result has not been to a great extent counter- 
balanced by the confusion which the introduction of a large number of 
names to designate trivial and often fanciful varieties of disease, and the 
pains taken to discriminate between conditions which are essentially iden- 
tical, have tended to create. 

But there is considerable excuse for minuteness of description and com- 
plexity of nomenclature of skin diseases, in the facts — that the skin is an 
extremely complicated organism, any one or all of the constituents of which 
may become the seat of almost any of the various morbid processes which 
have been considered in a former section of this work ; that it differs greatly 
in character in different parts of the body, and is hence not equally liable 
everywhere to the same affections, or even to present identical appearances 
under the influence of the same disease; and, lastly, that it subserves 
various important functions, all of which are liable to modification or im- 
pairment in the presence of morbid processes. 

A. Classification and Definition of Terms. 

TTe shall not classify skin diseases either according to the anatomical 
elements of the skin which are involved, as has been done by Erasmus 
Wilson ; or according to their visible features, which constitutes the essence 
of Willan and Bateman's system ; nor indeed shall we follow any strictly 
logical scheme of classification. But we shall group them mainly in ac- 
cordance with their mutual pathological affinities, not hesitating, however, 
to depart from this arrangement whenever it seems of practical utility, or 
convenient on any other grounds to do so. 

There are certain terms in common use in the description of skin dis- 
eases, which we proceed in limine to enumerate and explain ; and the 



DEFINITION OF TERMS. 



275 



more especially as there will thus be afforded a suitable opportunity for 
indicating the principles of Willan's artificial, but nevertheless very simple 
and useful classification. 

1. Macula By this term is generally meant a spot or patch of dis- 
coloration which does not fade on pressure, and in which, therefore, there 
is some obvious and more or less persistent deposit or change of texture. 
Freckles, moles, and port-wine marks are good examples of maculae. 
Under the same term may be included the circumscribed discolorations 
due to escape of blood into the tissue of the skin. But these are better 
known by special names. Extravasations, from about a line in diameter 
downwards, are (from their supposed resemblance to flea-bites) designated 
'•'petechia' ; larger effusions, such as may result from the coalescence of 
several petechias, are called ' vibices' ; and such as present the ordinary 
characters of bruises are known as ' bruises' or 4 ecchymoses.'' It may be 
added, that the term 4 stigma' is sometimes employed to indicate small 
patches or spots of vivid but readily effaceable redness, due merely to con- 
gestion, which appear suddenly, and often precede the development of 
vesicles, papules, or the pocks of vaccinia or smallpox ; and that the term 
4 areola? or 4 hold' is applied to the ring, more or less broad, of redness 
which so often surrounds a definite spot of inflammation. 

Willan's eighth order of skin diseases was that of the macnlce, and 
included, amongst other affections, freckles, and the various forms of 
birth-mark. 

2. Exanthema, or rash These words are employed, in reference not 

to individual spots of disease, but to a more or less general eruption of spots 
or patches, which are inflammatory, and variously grouped, and in the 
first instance at any rate, red, fading on pressure, and but little elevated 
above the general surface of the skin. The exanthemata formed the third 
of Willan's orders ; and he included in it measles, scarlet-fever, nettle- 
rash, roseola, purpura, erythema, and erysipelas. It is obvious, however, 
that he has here grouped together affections of the skin some of which 
have little in common with the others, and that he has excluded several 
which should really be regarded as exanthemata. Thus purpura is in no 
sense an exanthem, and erysipelas and erythema have no more right to 
that name than has acute eczema or impetigo. On the other hand, the 
eruptions of varicella and smallpox, and especially that of typhus, should 
certainly be regarded as exanthems. The term 4 exanthem' should, in- 
deed, be applied exclusively to the several eruptions which attend and 
characterize the infectious fevers. 

3. Papula or pimple — This is a small elevation at the surface of the 
skin, generally accumulated or pointed, but sometimes rounded, and rarely 
exceeding the size of a lage pin's head. It is very commonly congested, 
but by no means invariably so, and often attended with much itching. 
Papules are produced in various ways. In the condition known as 'goose's 
skin' there is a temporary production of them at the orifices of the hair- 
follicles in consequence of the contraction of the arrectores pili ; and in the 
same situation papules often arise from the concentric accumulation of epi- 
dermis and sebaceous matter entangling young hairs. The pearly concre- 
tions so common in* the sebaceous glands of the eyelids constitute another 
form of papule. Typical papules, however, originate either in enlargement 
of the normal papillae of the skin, or in inflammatory exudation into the 
substance of the cutis. 



276 



DISEASES OF THE SKIN 



The papirfce constituted Willan's first order, and comprised the various 
diseases known as strophulus, lichen, and prurigo. 

4. Tubercles are solid elevations of the cutis, ranging roughly from the 
size of a hazel-nut to that of a papule, varying considerably in form and 
texture, and presenting more or less permanence. In form, they may be 
hemispherical, spheroidal and attached by comparatively narrow bases, 
conical, lobulated or warty; and not unfrequently neighboring tubercles 
coalesce, and thus extensive surfaces may become irregularly thickened 
and lobulated. As to texture, it is sufficient, perhaps, to say that tubercles 
are sometimes cancerous, sometimes syphilitic, sometimes lupoid, sometimes 
due to inflammatory changes in sebaceous glands, sometimes simple warts. 

The tnbercula formed Willan's seventh order, and included boils, warts, 
molluscum, vitiligo, acne, sycosis, lupus, elephantiasis, and framboesia. 

A wheal may be regarded as a species of tubercle. Its special pecu- 
liarities are that it is of very transient duration, and that it forms a flat, 
generally circular, elevation, rarely exceeding a quarter or third of an inch 
in diameter. It sometimes presents a more or less vivid rosy tint, but is 
frequently pale, and in either case generally surrounded by a halo of con- 
gestion. It is usually attended with much itching. A wheal represents 
an early stage of inflammation ; and the swelling which characterizes it is 
due to effusion from the vessels of the part. Wheals may run together, 
and thus form bands or patches of considerable extent. 

5. Vesicles are small accumulations of fluid, generally between the horny 
layer of the epidermis and the rete mucosum. Individually they vary, for 
the most part, from the size of a pin's head downwards ; but they may be 
larger than that, and by mutual coalescence may form more or less con- 
tinuous tracts of considerable extent. They generally stand out promi- 
nently from the surface ; but where the horny layer of the cuticle is thick, 
as on the palm and sole, they often present no elevation whatever, are 
imbedded, and can be recognized only by the peculiar grayish or bluish 
tint which they present. The amount of fluid relatively to the solid con- 
stituents of vesicles varies very much ; and especially this is so if the vesi- 
cles are of inflammatory origin, inasmuch as the fluid effusion is then often 
associated with manifest thickening of the subjacent cutis and with over- 
growth of the involved epidermis. Indeed, owing to- this circumstance, 
the distinction between vesicles and certain forms of papules becomes 
purely arbitrary. Certain vesicles (sudamina) appear to be simply due to 
accumulation of sweat between the layers of the epidermis, and their con- 
tents are pellucid and acid. Generally, however, vesicles are the result of 
inflammation, spring up on a congested surface, and present contents which 
are alkaline, and, according to their age or other circumstances, trans- 
parent, milky, or tinged with the coloring matter of the blood. 

The vesiculce formed Willan's sixth order, and were made to embrace 
varicella, vaccinia, herpes, rupia, miliaria, eczema, and aphthae. 

6. Bullce or blebs may be regarded as having the same relationship to 
vesicles that tubercles have to papules. The line of separation between 
vesicles and bullae is quite artificial ; generally speaking, however, a vesicle 
the size of a split pea would be termed a bulla. Bullae usually vary be- 
tween this size and that of half a walnut. Occasionally they attain the 
bulk of an orange. But when thus large they are very often elongated and 
even sinuous as to their base, and their elevation is proportionately reduced. 
Their contents are identical with those of vesicles. 



DEFINITION OF TERMS. 



The hullce were Willan's fourth order, and comprised pemphigus and 
pompholyx — affections which are now regarded as identical. 

7. Pustules are accumulations of pus within or beneath the epidermis. 
They vary in size and form, and also in the degree in which they involve 
the deeper tissues of the skin. They sometimes commence as vesicles, the 
contents of which gradually suppurate; but very frequently they are puru- 
lent from the beginning. They are generally covered, as vesicles are, by 
the horny layer only, sometimes, however, by the whole thickness of the 
epidermis. The inflammation attending the formation of a pustule is much 
more intense than that which causes a vesicle or bulla, and consequently 
we find, as a rule, much more marked congestion, thickening, and indura- 
tion of the surrounding and subjacent parts in the former than in the latter 
case. 

The pustulce were Willan's fifth order, and included impetigo, porrigo, 
ecthyma, variola, and scabies. 

8. Furfura or scurf is the name given to the thin bran-like scales, which 
separate from the surface of the skin on the subsidence of many of the ex- 
anthems, and which so commonly form upon the scalp. Scurf consists 
either of thin plates of epidermis or of a mixture of epidermis and seba- 
ceous matter. 

9. Squamce or scales only differ from scurf in the fact that the plates of 
detached epidermis which constitute them are of larger size. They vary 
considerably, however, in size, thickness, color, and consistence. Thus, 
they may be as much as a square inch in area, or even larger ; they may 
be as thin as flakes of scurf or several lines in thickness, in the latter case 
being always more or less distinctly laminated ; they may have the color 
of the skin, or present various tints of yellow or brown ; and they may be 
soft or hard, friable or tough. Some of these peculiarities depend on the 
amount of fluid which has been diffused among the epidermic laminae: dur- 
ing the process of their formation. The detachment of scurf or scales is 
called 4 desquamation.' 

Willan's second order was that of squcwncB, and comprised lepra, psoriasis, 
pityriasis, and ichthyosis. 

10. A scab or crust is a concretion formed upon some diseased surface 
by the drying up of the exudation which has taken place from it, and 
generally comprises therefore some of the normal elements of that surface, 
namely epidermis and sebaceous matter. The exudation may be either 
serum, pus, or blood, alone or combined in various proportions ; and it is 
obvious that, according as these occur singly, or intermixed or combined 
with sebum or epidermis, will the color and other physical characteristics 
of the resulting scabs vary. Serum alone dries into thin yellowish or 
brown translucent flakes, pus alone into greenish scabs of some thickness, 
and blood into crusts which are black or nearly so. The admixture of 
sebaceous matter with serum or pus imparts to the resulting scab the color 
and general aspect of gum or honey, and that with blood a brown or red 
tint. When many particles of epidermis are mixed with simple serous 
exudation, as in cases of acute eczema, the concreted product often assumes 
a powdery character and the color of brimstone. Crusts vary much in 
thickness, and are occasionally of conical form. 

It is needless to discuss the meaning of the terms 'excoriation, 'fissure,' 
'ulcer,' 'cicatrix,' and many others which are in common use and generally 
understood. 



2?8 



DISEASES OF THE SKIN. 



B. Tendency of spots and patches of skin disease to assume a circular 

form. 

Before proceeding to the description of the different diseases it may be 
worth while to point out that, while eruptions present great varieties of 
grouping or arrangement, the individual spots or patches almost invariably 
have at first a rounded shape, and that as they grow they maintain that 
shape unless the form of the surface on which they are situated, or the 
direction of its grooves, or the union of neighboring patches with one 
another, interferes with their regular development. Thus a vesicle, a bleb, 
a pustule, a papule, or a tubercle is almost invariably circular in the first 
instance ; so is a patch of erythema, lepra, or pityriasis ; and so also are 
the vegetable parasitic affections. In many cases, moreover, there is a 
tendency for the central part of the inflamed patch to undergo resolution 
whilst its periphery is extending ; and then it not unfrequently happens 
that the enlarging ring breaks up into fragments, and that some of these 
form the starting-points of other circles or segments of circles. It is easy 
to understand from this statement how the sinuous, serpentine and other 
curious forms which skin diseases frequently assume are produced. 



II. ERYSIPELAS. 

Definition. — An acute inflammation of the skin, originating for the most 
part in the neighborhood of wounds or sores, attended with much redness 
and infiltration and severe febrile disturbance, and characterized by a 
marked tendency to spread over the surface, and (especially in the presence 
of wounds) to become contagious. 

Causation Erysipelas is either traumatic or idiopathic ; that is, it 

either occurs in connection with wounds, or arises apparently spontaneously 
on surfaces which were previously sound. The former variety may be 
developed, therefore, on any part of the body on which wounds have been 
inflicted, or wherever conditions equivalent .to wounds exist, as, for ex- 
ample, in connection with other forms of cutaneous disease, and about the 
umbilicus in newly-born children; further, erysipelatous inflammation, or 
a modification of it, may attack parturient women. Idiopathic erysipelas 
occurs most frequently on the face. That erysipelas is highly contagious 
among surgical patients, and that its presence in a lying-in hospital induces 
a rapidly fatal form of puerperal fever among the mothers, and erysipelas 
of the newly-born infants, are facts now entirely beyond dispute. It is 
obvious that in these cases the disease is propagated by the transmission 
from the sick to the healthy of some poisonous matter capable of repro- 
ducing it; and from the circumstance that the inflammation always begins 
at the very spot where a wound or rawness exists, it is reasonable to as- 
sume that the poison has been inoculated at that spot. It is by no means 
clear that erysipelas spreads in the same way to those whose skin and 
mucous involutions are sound. No doubt many, and apparently very 
striking examples of such spread are recorded, but, on the other hand, 
good authorities deny its occurrence, and certainly it is far from common. 

In close relation with the subject which has just been considered is the 
question, whether erysipelas is to be regarded as a specific fever or as a 



ERYSIPELAS. 



279 



mere local inflammation. The former view is generally entertained, at all 
events in this country ; and the chief grounds on which it rests are : first, 
the manifest contagiousness of the disease under certain conditions ; second, 
the existence, which is obvious in idiopathic cases, of a distinct, though 
short, stage of incubation ; third, the affirmed enlargement and tenderness 
of lymphatic glands prior to the appearance of the skin affection, indicating 
that the erysipelatous inflammation is secondary to constitutional disturb- 
ance ; fourth, the discovery of bacteria in great abundance in the inflamed 
tissues and in the lymphatic spaces and vessels connected with them, and 
the fact that these bacteria may be propagated, with the inflammation 
which they accompany, by inoculation upon the lower animals ; and, 
lastly, the close resemblance which exists between the general morbid 
anatomy and symptoms of this disease and those of the specific fevers. 
The arguments in favor of its being a non-specific and local disease are 
chiefly the following : — first, the fact that the disease appears to arise con- 
stantly from exposure to cold and various other non-specific causes ; second, 
that a previous attack, so far from precluding subsequent attacks, as is gene- 
rally the case with the infectious fevers, encourages them, as is the com- 
mon rule with non-specific inflammations ; third, that contagiousness is not 
an attribute of the specific fevers only, for many varieties of simple in- 
flammation — catarrh, ophthalmia and the like — are apt to spread by con- 
tagion ; and lastly, that the symptoms and morbid processes which attend 
erysipelas can be fully acounted for as being the consequences of the local 
inflammation. We agree with Hebra in the belief that erysipelas is not a 
specific fever, but a local disease ; that is, a local disease in the same sense 
as inflammations of the lungs, kidneys, and other organs are local diseases. 

Apart from contagion, to which, as we have shown, erysipelas is largely 
due, the causes of the disease seem to be identical with those of other 
forms of inflammation, especially exposure to cold and atmospheric changes 
generally, and local irritations of various kinds. The causes which pre- 
dispose to it are partly breaches of surface, partly constitutional conditions, 
such as may result from long-continued indulgence in drink, and poor 
living. 

Morbid anatomy. — The earliest local changes consist in a circumscribed 
blush of more or less vivid redness, which fades on pressure, and the accu- 
mulation of inflammatory products — lymph and corpuscles — in the sub- 
stance of the cutis and subcutaneous connective tissue. The inflamed 
patch becomes consequently thickened, hard, and brawny. Its margin is 
well-defined, and obvious to both eye and touch. The character of its 
surface varies according to the part affected. If the skin be originally 
smooth and delicate, it becomes yet smoother, and shining ; if it be coarse, 
all its markings are apt to get magnified and its coarseness therefore exagge- 
rated. The inflammation gradually spreads by continuity to the surround- 
ing healthy parts, and thus extending may ultimately involve a very large 
area — the entire surface of a limb for example, or that of the head and 
face, and occasionally (it is said) that of the whole body. As it spreads, 
however, the parts first affected undergo changes, their tension diminishes, 
their redness becomes less vivid and assumes a yellowish or brownish tint, 
and resolution, preceded by desquamation, presently takes place. Thus 
all stages of the disease may be present at the same time. Occasionally 
erysipelas (which is then termed 1 erratic') disappears in one part and 
breaks out elsewhere, and may thus be prolonged by successive outbreaks. 

The intensity and results of the inflammatory process vary considerably 



280 



DISEASES OF THE SKIN. 



in different cases. In some the degree of inflammation present is no greater 
than that attending the affections which we shall shortly describe under 
the name of erythema. In some the effusion is so abundant that it infil- 
trates the subcutaneous connective tissue, and well-marked oedema becomes 
developed. This is common wherever the cutis is thin and the subcuta- 
neous connective tissue lax, as they are in the eyelids and scrotum. In 
some cases the inflammation goes on to the formation of pus, which, like 
the oedema, occupies mainly the subcutaneous tissue. The suppuration is 
frequently diffused ; but sometimes, and especially in the eyelids and else- 
where about the face and head, forms circumscribed abscesses. In some 
cases again, and mainly in connection with suppuration, the connective 
tissue sloughs ; and sometimes the skin itself becomes gangrenous. When 
oedema, suppuration, or sloughing is present, the inflamed surface becomes 
paler and duller, perhaps more or less livid, and acquires a soft 'boggy' 
feel, or pits on pressure. Vesicles and bullae not unfrequently form on 
erysipelatous surfaces, and may become converted into pustules. Subse- 
quently excoriations and scales or crusts necessarily make their appearance. 
[To this variety of erysipelas the name erysipelas phlyctenoides was for- 
merly applied. It is now called by Hebra E. vesiculosum, E. bullosum, 
E. pustulosum, or E. crustosum, according to the appearance it presents 
when it comes under observation.] Bullae also, containing sanious fluid, 
attend the progress of superficial gangrene and subcutaneous sloughing. 

Although erysipelas is commonly limited in depth by the fascia?, it is 
not invariably thus limited; and hence subjacent organs are apt to get 
involved. Thus erysipelas of the trunk may produce inflammation of the 
peritoneum, pleurae, or pericardium ; erysipelas of the neck oedema of the 
larynx; and erysipelas of the head meningeal inflammation. Again, it 
not unfrequently creeps from the skin into the mucous orifices — into the 
auditory meatus, causing inflammation of the ear, or into the nose or 
mouth and thence to the fauces and larynx. On the other hand, cutaneous 
erysipelas may result from extension of faucial, aural, and other such in- 
flammations. 

There is a marked tendency in erysipelas for the veins, and especially 
for the absorbents, to become affected. As regards the absorbents, indeed, 
it is not only common to trace red lines from the seat of inflammation to 
the nearest glands, which get enlarged and tender ; but some authors go 
so far as to maintain that a patch of erysipelatous inflammation is always 
preceded by inflammatory enlargement of the neighboring lymphatic glands. 
Phlebitis, again, with suppuration in or around the veins, occasionally takes 
place, and occasionally pyaemia. 

Repeated attacks of erysipelas lead to permanent thickening and indu- 
ration, and sometimes to very considerable overgrowth, of the skin and 
subjacent connective tissue. Indeed, according to Yirchow, it is to such 
attacks frequently repeated that the hypertrophy of these parts in elephanti- 
asis is mainly due. 

There is no special affection of internal organs in erysipelas. In the 
early stages of the disease the blood contains an excess of fibrine and white 
corpuscles; but subsequently it tends to assume the characters commonly 
observed in the later stages of febrile disorders. Post mortem it is gene- 
rall} r found dark, and fluid or pitchy, with little tendency to coagulate, 
and still less to the separation of fibrine. It stains the inner surface of the 
heart and vessels. The organs are generally soft, and the lungs, liver, 



ERYSIPELAS. 



281 



kidneys, and especially the spleen, congested. Pneumonia is not uncom- 
mon. Decomposition is rapid. 

Symptoms and progress The symptoms of erysipelas are mainly those 

of the local process and of inflammatory fever ; but they are often compli- 
cated with those of intercurrent lesions ; and they vary in their severity, 
both actually and relatively, according to the intensity of the inflammation, 
its extent, and its situation. In idiopathic erysipelas the local signs are 
generally preceded by an interval, varying from a few hours to two or three 
days, in which the patient experiences slight febrile symptoms, sometimes 
rigors ; and in which, according to certain authors, some swelling and 
tenderness of lymphatic glands may be detected. At the end of this time 
an inflammatory blush appears, generally on some part of the face, attended 
with heat and tingling, and tenderness on pressure. With the appearance 
and extension of this, the febrile symptoms increase; there are headache 
and pains in the limbs, rise of temperature with dryness of skin, rigors, 
increased rapidity of pulse, furring of the tongue with thirst, loss of appe- 
tite, and nausea or sickness, generally some constipation, occasionally, how- 
ever, diarrhoea, and scanty highly-colored urine. There may be some 
degree of drowsiness, but sleep is restless and disturbed with dreams. If 
the case be mild, the symptoms may subside and the patient become con- 
valescent in the course of two or three days. But if the inflammation con- 
tinue to spread, or in any way to increase in severity, the pulse gets rapid 
and feeble, the respirations hurried, the tongue more thickly coated and 
dry ; and delirium, at first only when the patient is dropping to sleep or 
waking, but subsequently constant, comes on. Sometimes at this period 
diarrhoea occurs ; and the patient's evacuations may be passed into the bed. 
At this point also (that is, at the end of six or seven days) the patient may 
begin to amend. When, however, from the inherent severity of the attack 
or other circumstances, the case takes an unfavorable course, the symptoms 
assume a more distinctly typhoid character — marked mainly by great failure 
of muscular power, tremulousness of limbs, dry black tongue, entire want 
of control over the evacuations, and delirium, which is generally low and 
muttering, sometimes busy, like that of delirium tremens, and occasionally 
violent and maniacal. As the fatal end approaches, the temperature often 
rises, the skin becomes bathed in sweat, the pulse rapid, perhaps irregular, 
and almost imperceptible, the respirations quick and noisy, and the delirium 
passes into coma. 

The temperature in erysipelas is always above the normal, but rarely 
exceeds 106° ; and although it is liable to considerable variation, there is 
a general tendency to an evening rise and a morning fall. The urine is 
always scanty, presents an excess of urea and diminution of chlorides, and 
often contains small quantities of albumen between the fourth and seventh 
or eighth day of the disease. The motions are generally dark-colored, 
watery, and fetid. The course and event of the disease are often modified 
by the association with it of some one of the various complications which 
have been previously enumerated. Thus, oedema of the larynx and con- 
gestion of the lungs will each add symptoms and dangers of its own. And 
similarly inflammation of the membranes of the brain, phlebitis, and 
pyaemia, will each bring its characteristic indications. Further, the health 
and circumstances of the patient at the time of seizure for the most part 
largely modify the character and severity of his attack. 

Erysipelas which seems to affect only the cutis is termed ' simple erysi- 
pelas when the subcutaneous connective tissue is largely involved as 



282 



DISEASES OF THE SKIN. 



well, the affection is called 1 phlegmonous erysipelas ;' when oedema, sup- 
puration, or sloughing supervenes, the erysipelas is often termed ' cede ma - 
tous,' 1 suppurative,' or ' gangrenous,' as the case maybe. But these 
distinctions are essentially artificial, for the various forms of erysipelas run 
into one another, and several, or all of them, may be present at the same 
time in the same case. 

Treatment Having regard to the tendency which erysipelas has to 

become contagious, it is always important that erysipelatous patients 
should be removed from the neighborhood of those who are especially liable 
to take it ; and that, in fact, all such precautionary measures should be 
adopted as have been already recommended in relation to the infectious 
fevers. The local treatment in mild cases is of little importance ; and, 
even in severe cases, has perhaps little influence. Collodion, nitrate of 
silver in saturated solution, solution of sulphate of iron, tincture of iodine, 
and mercurial ointment, have each been strongly advocated. Flour, dusted 
thickly over the surface,- is also recommended. There is an obvious dis- 
advantage in employing anything which conceals or masks the diseased 
surface ; for which reason several of the above applications are objection- 
able, even if useful on other grounds. Mild astringent lotions and oint- 
ments, such as those of lead, zinc, and iron, are probably as useful and 
convenient as any. Cold-water dressing, which has commonly been dis- 
countenanced in this country, is strongly recommended by Hebra, and is 
undoubtedly useful. Warm applications and poultices are not generally 
desirable. It is rarely needful to abstract blood locally, or to make inci- 
sions, except for the purpose of letting out matter, or relieving tension. 
In reference to the internal treatment of the disease, we must recollect 
that mild cases get well spontaneously, and that more serious cases very 
soon present symptoms indicative of great debility and of blood-poisoning. 
For these reasons it seems obvious that depletion can never be necessary; 
but that, as a rule, the strength of the patient should be sustained, and the 
free action of his excretory organs encouraged. To support strength such 
nourishment as he can take should be administered frequently and in small 
quantities ; milk, eggs, beef-tea, arrowroot, sago, and the like, are most 
suitable for the purpose ; to which, if the pulse be failing and the tongue 
dry, brandy, wine, or ale (if the patient prefer it) should be added. To 
promote the action of the emunctories, purgatives should, if necessary, be 
from time to time administered, and the patient may be put on a course 
of mild diuretics or diaphoretics. Ammonia, camphor, iron, quinine, have 
all been employed in the treatment of erysipelas. It is questionable, how- 
ever, whether any one of them is of material use in the early stages of the 
disease. But stimulant medicines are clearly indicated when typhoid 
symptoms are present ; and tonics are, of course, highly valuable during 
convalescence. Hyoscyamus and opium are not generally indicated, and 
must always be given with caution. But in cases where there is great 
irritability, or persistent want of sleep, they, chloral hydrate, or other 
sedatives are valuable. 



III. CARBUNCLE. (Anthrax.) BOIL. (Furunculus.) 



Definition — A boil or carbuncle is an intense inflammation occupying, 
within a well-defined area, the entire thickness of the skin (inclusive of 



CARBUNCLE. BOTL. 



283 



the subcutaneous connective tissue), and attended almost always with cir- 
cumscribed suppuration and the formation of a slough. 

Cavsation Boils and carbuncles are usually considered to be constitu- 
tional disorders ; and undoubtedly they are common in persons of broken- 
down constitutions, and in those who are recovering from diseases of 
various kinds. Diabetic patients are said to be specially liable to them. 
But, on the other hand, they are common in those who appear to be other- 
wise in perfect general health ; often occurring in connection with acne 
and other forms of skin disease, or induced by local irritation, such as 
arises from friction, poulticing, the contact of unhealthy discharges, and 
(as pathologists know to their cost) the soakage of dead bodies. It cannot 
be denied that there is, in many cases, a predisposition to boils and car- 
buncles, and that this predisposition may be induced. We are disposed, 
however, to regard the disease as essentially local, and due to the operation 
of local causes ; and to believe that, like acne, it is mainly an affection of 
the sebaceous glands and their surroundings. 

Morbid anatomy. — The morbid process commences with circumscribed 
thickening and induration of the deeper tissues of the skin, attended from 
the beginning, or soon followed by a little elevation and redness of surface. 
The resulting nodule increases more or less rapidly in area and thickness 
and consequently in prominence until, at the end of a few days, it has 
attained its full development. It then presents a more or less circular 
base, varying in diameter from half an inch to three or four inches or 
more ; is intensely congested, and surrounded with an areola of congestion 
and often much oedema; and forms a considerable elevation, which is 
conical or flat, according as the area involved is small or large, and pre- 
sents on its summit a vesicle or group of vesicles, containing serous or 
sanious fluid or pus. Each vesicle soon bursts, discharges its contents, 
and exposes in its floor a small round orifice, from which, even at this 
time, an ash-colored slough protrudes. When there are more vesicles than 
one, they generally run speedily together ; and then by sloughing of the 
intervening papillary layer of the cutis the subjacent orifices coalesce, so 
as to form a more or less extensive irregular excavation, the floor of which 
is formed as are the floors of the primary orifices by underlying sloughy 
tissue. The slough thus exposed has been gradually forming during the 
progress of the disease, and involves the deeper structures of the skin and 
sometimes subjacent parts ; mainly, however, it consists of connective 
tissue saturated with pus, and presenting a yellowish or grayish color, and 
a resemblance to wash-leather. It now gradually becomes detached from 
its bed, and is at length discharged through the orifice which has formed 
over it. After its separation the excavation which it leaves granulates, 
the inflammatory thickening of the surrounding tissues subsides, and the 
parts gradually return to their normal condition, except that a permanent 
scar remains. The distinction between a boil and a carbuncle is arbitrary ; 
a boil is comparatively small, generally conical in shape, and opens by a 
single orifice ; a carbuncle is characterized by its size and flatness, and 
particularly by the formation of more orifices than one, and the presence of 
superficial gangrene. Carbuncles very often arise in the median line of 
the trunk behind, and especially in the nape of the neck. They some- 
times attack the lips (more particularly the upper lip) and are then char- 
acterized by great malignancy. The lymphatics and veins are apt to get 
inflamed in these affections ; and, of carbuncle especially, pyaemia is a 
very common sequel. 



284 



DISEASES OF THE SKIN. 



Symptoms. — The local symptoms are heat, tingling, and aching, with 
throbbing and great tenderness, which are often followed by pain and red- 
ness of the lymphatic vessels and glands in relation with them. There is 
generally, even with a boil, some amount of febrile disturbance; and with 
a carbuncle the febrile symptoms may be very severe. Indeed, in the 
latter case, the general symptoms are almost exactly like those which 
attend the progress of erysipelas, and may be at least as serious as those 
of the worst forms of that disease, and the consequences may be fully as 
grave and fatal. 

Treatment.— The general treatment of carbuncle is identical with that 
of erysipelas. For local treatment free incisions are generally recommended, 
which, if the carbuncle be large, should be crucial. Pain and tension are 
greatly relieved by them; but it is doubtful if they check the progress of 
the disease or materially modify its course. Caustic applications, and 
especially the free use of caustic potash, are recommended by some. 
Poultices and warm-water dressings are generally of service. Hebra 
strongly advocates the employment of cold in the form of compresses 
saturated with ice-cold water, to be applied so long as they are not dis- 
agreeable to the patient. 

In the treatment of boils, which often show a tendency to recur, many 
internal medicines — among others yeast, quinine, and mineral acids — have 
been recommended, with the object of preventing that recurrence. But 
it is more than doubtful whether any of them has a specific influence. It 
is, of course, always desirable to treat any associated malady which may 
tend to keep up a condition of system favorable to the development of boils. 
Boils may be dealt with locally on the same principle as carbuncles ; and 
some authorities believe they may be made to abort by the early applica- 
tion to them of strong ammonia, caustic potash, acid nitrate of mercury, or 
some other such agent. 



IY. ERYTHEMA. ROSEOLA. URTICARIA. PITYRIASIS. 

Causation and description The above affections embrace a consider- 
able number of morbid states of the skin which resemble one another in 
the facts, that they are for the most part slight, superficial, and essentially 
short-lived inflammations ; that they have little or no tendency to suppu- 
ration, ulceration, or gangrene, but end usually in furfuraceous desquama- 
tion ; and that they are often variously figured and distributed, and are 
never contagious. 

There is great confusion amongst dermatologists as to the distinctions 
between erythema and roseola. Dr. Willan describes the former as a 
nearly continuous redness of some portion of the skin, and the latter as a 
rose-colored efflorescence variously figured. But even he includes under 
the head of ' erythema' affections which, according to his definition, should 
be varieties of roseola; while, on the other hand, several conditions are 
now universally termed roseola which, according to the same definition, 
ought to be regarded as erythema — we refer to so-called 'roseola vaccinia.' 
The formation of wheals is the special characteristic of urticaria ; but 
wheals arise under so many different conditions, and so closely resemble 
some of the eruptions which are termed erythema, that it is impossible to 



ERYTHEMA. 



285 



draw any sharp line between them. For these reasons we propose to 
discuss erythema, roseola, and urticaria together; and, although we shall 
preserve the names, we shall regard them as indicating trivial, and in some 
cases imaginary, distinctions between things which are essentially the same. 
Pityriasis we look upon as simply the desquamating stage of the different 
forms of erythema. 

Some of these affections are of local origin, due to the action of direct 
irritants ; but many of them, as is shown by attendant circumstances, and 
by their simultaneous development in different parts, are distinctly trace- 
able to causes acting from within. The former, if extensive, may be 
attended with febrile disturbance. The latter are generally so attended ; 
and, indeed, not unfrequently appear in the course of some rheumatic, 
gouty, or other inflammatory or febrile attack. The local symptoms are, 
for the most part, more or less intense itching, burning, stinging, arid 
occasionally aching. 

A. Erythema simplex is a pretty uniformly diffused redness, occupying 
an area of very irregular size and form. The redness is generally bright, 
disappearing on pressure ; and is attended with slight thickening and ele- 
vation of the skin ; and presents a fairly well-defined margin. It often 
spreads from its primary seat over the neighboring skin, and is not un- 
frequently erratic. There is a very close resemblance between certain 
varieties of erythema and the simplest form of erysipelas ; between which, 
indeed, it is impossible in many cases to distinguish. One variety of ery- 
thema is produced by the direct operation of local irritants, as by the 
application of a mustard plaster, or by the constant flow of catarrhal 
secretions from the nostrils or of saliva from the mouth, and in children, 
when from want of cleanliness the urine is allowed to fret the thighs, 
groins, and other neighboring parts. Intimately related to this is the con- 
dition known as ' e. intertrigo,'' in which inflammation is induced, either 
by the attrition of opposed surfaces of skin, or by the effect on such surfaces 
of the decomposing and fetid sweat which accumulates between them. This 
is common, in children and fat adults, in the groins and between the upper 
parts of the thighs and the external genital organs ; and in fat women 
between the pendulous mamma and the surface with which it lies in con- 
tact. The persistence of the cause in erythema intertrigo tends to keep 
up and intensify the irritation ; and consequently excoriation and ulceration 
are apt to supervene. Another variety of erythema is termed * e. Iceve' 
This is the superficial inflammatory blush which often appears in limbs, 
and especially in legs, which are the seat of anasarca. The redness is 
generally somewhat unevenly distributed, and is attended with tenderness 
and itching, tingling or aching. Vesicles, which rupture and allow of the 
escape of the dropsical fluid, are very apt to form on the surface ; and not 
unfrequently the inflammation passes into distinct erysipelas, or superficial 
gangrene ensues. A further variety of erythema is known by the name 
of 'pityriasis simplex.' This occurs on various parts of the body, but is 
especially common in the form of circular or oval patches on the lips, chin, 
and other parts of the face, in children and persons of delicate skin. The 
patches present a slight degree of redness, and are very early covered with 
thin branny scales, or scurf, whence the name pityriasis has been given to 
them. This affection is also of common occurrence in the hairy scalp, 
when it is usually called 4 p. capitis' or 4 dandriff' In this case the 
branny scales, which form pretty abundantly and, owing to the presence 



286 



DISEASES OF THE SKTN. 



of hair, tend to accumulate, contain, as might be expected from their soil 
a large admixture of sebaceous matter. 

B. Erythema multiforme Under this term, which we owe to Hebra, 

are included e. papulatum (in the sense in which Hebra employs that 
term), e. circinatum, e. iris, e. marginatum, and e. gyratum. The earliest 
stage of the affection is characterized by the appearance of small, flat, 
circular, congested elevations of the cutis, attended with itching, and dif- 
fering little if at all from wheals (e. papulatuni). Their development may 
cease at this point ; but in most cases they pass on to a second stage ; the 
wheal gradually increases in area until perhaps it measures half an inch or 
an inch in diameter; and while thus increasing, its central portion probably 
subsides, its periphery forming a congested tumid ring (e. circinatum) ; 
or the enlargement of the inflamed patch is effected by the development 
of successive concentric rings of inflammation, separated by zones of fairly 
healthy skin, and the affection known as ' e. iris' results. Further, the 
spots of e. papulatum, and the patches of the circinate form of the affec- 
tion, which may attain much larger dimensions than have been above 
assigned to them, tend in the course of their development to coalesce with 
one another, and thus to cover with more or less uniformity, round, oval, 
or sinuously-margined arece of several square inches, which, like the spots 
from which they sprung, are still for the most part characterized by a 
tendency to central subsidence, and marginal extension by a broad band 
of congestion. In their progress these k fairy rings' not unfrequently break 
up into segments, and hence after a while curved or sinuous erythematous 
bands alone remain. These latter forms of the affection constitute e. mar- 
ginatum and e. gyratum respectively. The several varieties of erythema 
above described occur on different parts of the body, and are sometimes 
very extensively distributed; they are most common, however, on the 
backs of the hands and wrists and corresponding parts of the lower ex- 
tremities. They are generally attended with febrile symptoms, which, if 
the eruption be extensive, may run high — the temperature rising tempo- 
rarily to 104° or more ; and they are very apt to be associated with rheu- 
matism or gout. Individually the inflamed patches seldom last more than 
a week or ten days, sometimes not longer than two or three days, and 
terminate in desquamation. But the eruption may be continued by suc- 
cessive crops for several weeks. Occasionally it assumes a chronic form, 
or the patient remains for years liable to more or less frequent outbreaks. 
It sometimes happens, that the wheals or rings become the seat of intra- 
cutaneous hemorrhage (purpura urticans?) which generally occurs in the 
form of minute coalescing points, and is for the most part limited to their 
central areae ; and that this leads to the death of the involved cutis and 
separation of eschars, or to the development of sanguinolent blebs, and 
unhealthy ulcers. Further, vesicles or bulla?, containing limpid fluid, not 
unfrequently arise in more or less abundance upon the surface of the ery- 
thematous patches, constituting varieties of herpes and pemphigus. 

C. Erythema nodosum is characterized by the appearance of round or 
oval red patches varying, roughly speaking, from ^ inch to 1^- inch in 
diameter. They rise in a lenticular form above the surface in relation 
with which they are developed, and are consequently most elevated at the 
centre, where also their redness is most intense ; and in both of these re- 
spects they fade away gradually at the margins. They are hot, hard and 
tense to the touch, and to the patient tender and attended with aching 
They occur chiefly scattered over the anterior aspect of the leg, between 



ROSEOLA. 



287 



the ankle and knee, but sometimes on the lower part of the thigh. They 
occasionally appear also on the corresponding parts of the arm ; and in 
very rare cases stud the whole surface of the body, including fingers, toes, 
and face. The patches generally increase in number for a few days — each 
one lasting perhaps a week. They get dusky in color after a day or two, 
and generally acquire a bluish aspect when exposed to cool air ; they pre- 
sent successively the greenish and yellowish tints of fading bruises, and 
end with desquamation. E. nodosum is for the most part preceded by 
and attended with febrile symptoms, and not unfrequently associated either 
with rheumatic pains or distinct rheumatism. It is most common in 
young persons, especially females, above the age of puberty. The affec- 
tion described by Willan under the name of e\ tuberculatum is a modifi- 
cation only of e. nodosum. We believe, too, that the roseola autumnalis 
of the same author is essentially the same disease ; and may add that there 
is little, if any, difference betweeu a chilblain (pernio) and a patch of e. 
nodosum. 

D. Erythema fugax is the name given to the evanescent patches of 
redness which appear on the face, neck, chest, and other parts, in hysteri- 
cal and dyspeptic patients. This is closely related to the patches of red- 
ness, termed ' roseola,'' which are sometimes observed in cholera, smallpox, 
and other fevers, and may be held to include those which are so commonly 
associated with the vesicular and other inflammatory skin diseases of young 
children. 

E. Roseola, as has been already explained, is a name of common and 
somewhat indefinite application. This, or still better perhaps the name 
' r. rubeoloides,' may properly be applied to an affection of the skin, of 
which Willan seems unnecessarily to make two varieties, namely, r. cestiva 
and r. infantilis. This rash seems generally to be preceded for a day or 
two by slight febrile disturbance, and, like so many other rashes, to make 
its appearance first on the face and neck, whence it quickly spreads over 
the general surface of the skin. It consists of rose-colored flatly elevated 
circles, fading at the periphery into the surrounding healthy skin, and dis- 
appearing on pressure, varying perhaps from |- to ^ inch in diameter, and 
often running together over extensive tracts so as to form an imperfect 
network with scalloped interstices. There is often some general but slight 
tumefaction of the surface, and a passing chill is apt to render the rash 
temporarily of a peculiar violet tint. Itching is frequently complained 
of; and the fauces are sometimes implicated. The affection generally 
disappears within four or five days after the first appearance of rash. It 
is quite unattended with danger ; and of little importance, but for its re- 
semblance to measles and rotheln or epidemic roseola on the one hand, 
and to urticaria on the other. 

F. Urticaria or nettle-rash has been subdivided by dermatologists into 
numerous varieties. It seems unnecessary, however, to make more than 
two, namely, u. acuta or febr His, and u. chronica or evanida. 

The more common form of the disease is u. febr Hi s. In it the appear- 
ance of the eruption is often, if not always, preceded by more or less febrile 
disturbance, with probably some degree of gastro-intestinal derangement;, 
and these symptoms continue during the prevalence of the eruption, which 
rarely exceeds a few days or a week. The eruption, which is attended 
with much local heat and itching, generally comes out in the evening or 
night, and disappears in the morning, and is continued for a few days by 
successive nocturnal outbreaks. In many cases,, however, it appears at 



283 



DISEASES OF THE SKIN. 



irregular intervals both night and day. The wheals arise quickly, seldom 
remain out longer than a few hours, and on subsiding sometimes leave 
behind them a slight yellowness of skin and a tendency to desquamation. 
They may appear simultaneously or in successive crops on any or all parts 
of the body; but are most common on the face, back, front of the chest, 
and flexures of the joints. The lips, tongue, and interior of the mouth 
are occasionally affected. The wheals are sometimes scattered; but are 
more generally clustered and running together, and may then cover large 
tracts. Their presence is often attended with subcutaneous oedema and 
stiffness of parts. Scratching and other forms of local irritation tend to 
increase their size, number and duration. Occasionally febrile urticaria is 
due to the use of certain alimentary substances, such as shell-fish and 
pork, which, either from some acquired poisonous quality, or from some 
idiosyncrasy in the subject, act in a special way on the system. In severe 
cases the symptoms come on rapidly, are very grave, and indeed may 
prove fatal. They are mainly rigors, failure of circulation, fainting, pre- 
cordial oppression, vomiting, and difficulty of breathing. They generally 
subside, however, in the course of a few hours. 

Chronic urticaria, which supervenes in some cases on the acute form, 
is generally unattended with marked fever. It shows itself for the most 
part, like that, in successive crops of eruption, which come out daily or at 
irregular intervals, for weeks, or months, sometimes for many years. A 
curious sub-variety of chronic urticaria is that which Sir W. Gull has 
termed 'factitious urticaria.' Here the eruption, although it may come 
out as in other cases in successive crops, is also readily produced by pres- 
sure or irritation. And thus the application of a ligature, or the passage 
of the finger-nail, is followed in a few seconds by the appearance of a line 
of confluent wheals, with an areola of congestion, which remains out for a 
minute and then disappears. 

Wheals more or less exactly resembling those of urticaria, are very often 
the result of the operation of local irritants. They are common in prurigo, 
scabies, and phthiriasis. They result from the prick of the ordinary 
stinging-nettle, and from the action of some species of jelly-fish. And 
they follow the bites of many insects, such as gnats, fleas, and bugs. In 
this last case, however, the wheals are persistent, and often last for a week 
or ten days. They probably constitute Willan's ' urticaria perstans.' 

The causes of urticaria are not well understood. Some of its severer 
forms are caused by poisonous matters received into the stomach, and act- 
ing through the medium of the circulatory system. It is natural, there- 
fore, to assume that other forms of urticaria must be due to gastrointes- 
tinal disturbance. That in many cases it really is so is probably beyond 
doubt. But it is equally certain that, in a large number of instances, 
especially of the chronic variety of the disease, there is no indication what- 
ever that the digestive functions are at fault. Mental emotion, hysteria, 
and uterine affections are sometimes assigned as causes of urticaria. 

Treatment. — Most of the erythematous inflammations which have just 
been described need little or no special treatment, either local or general. 
Many -of them must be regarded as parts, and indeed trivial parts, of more 
serious diseases — such as rheumatism ; and their treatment must merge in 
that of the more general malady with which they are associated. For 
most of them cooling or astringent lotions, such as cold water or lead-wash, 
are serviceable and agreeable; but for some of them, more especially e. 
intertrigo .and pityriasis., careful local treatment is generally essential. In 



PSORIASIS. 



289 



e. intertrigo the affected parts should be kept perfectly clean and free from 
acrid moisture, and opposed surfaces separated, if necessary, by a piece of 
lint anointed with some appropriate ointment. Dusting the surface with 
starch, oxide of zinc, fuller's earth, lycopodium or violet powder, or apply- 
ing astringent lotions or ointments, are often valuable measures. In pity- 
riasis cleanliness is equally essential, and the cure is often aided by the use 
of mild mercurial ointments. When the lower extremities are affected 
with e. nodosum ore. loeve, the patient should keep the recumbent position, 
with the legs elevated. The general treatment of these various affections 
should be mildly antiphlogistic and comprise cooling drinks and gentle lax- 
atives. In e. nodosum, however, it is frequently necessary to have recourse 
to tonics. And in urticaria, if it be either severe or chronic, special mea- 
sures must be adopted. If, for example, there be reason to suspect its 
dependence on poisonous substances taken into the stomach, an emetic or 
a purgative may be necessary ; if there be much abdominal pain, opiates ; 
if collapse, either ammonia, brandy, or other stimulants. In the chronic 
form of the disease few remedies have been found useful, but arsenic, 
mineral acids, alkalies, tonics, and change of air have often been recom- 
mended. 



V. PSORIASIS. {Lepra.) PITYRIASIS RUBRA. 

Causation and description. — We have shown that one of the events 
of the different forms of erythema is the formation of scurf ; we pass, 
therefore, naturally from their consideration to that of psoriasis, which is 
essentially also a superficial inflammation of the skin, attended with the 
development of scales. It is thus closely related to pityriasis, and cannot 
always be separated from it. Willan and his followers have distinguished 
psoriasis from lepra, but their distinctions are artificial ; and we shall, 
therefore, with Hebra and others, combine them in a common description. 

A. Psoriasis is characterized by the presence of defined, mostly circular 
tracts, in which the cutis is somewhat congested and raised ; while the 
epidermis over it is thickened and opaque, and tends to come away in large 
flakes. These, on their separation, leave behind a congested, irritable, 
and sometimes slightly excoriated surface, on which squamae are speedily 
reproduced. 

Psoriasis commences with spots or disks of slight congestion, over which, 
almost from the earliest moment, the cuticle assumes a scaly character ; 
but at first, and while they are in process of enlargement, the area of con- 
gestion usually extends beyond that of desquamation. 

The patches vary in size and shape. In some cases they are mere 
papules, a line or less in diameter ; in some they have a discoid form, 
measuring between 1 and \ inch across ; in some they form rings between 
(say) the size of a shilling and that of a crown-piece, inclosing a central 
area of comparatively healthy skin, which (especially if they become large) 
tend to break up into segments ; in some cases, again, partly by coalescence 
of adjoining patches, partly by innate irregularity of growth, they form 
patches of large size and irregular outline, covering, it may be, an entire 
limb or even the whole surface of the body. 

The squamae also vary in color, consistence, thickness, and form. These 
peculiarities are mainly due to the different degrees of rapidity with which 
19 



290 



DISEASES OF THE SKIN. 



they are developed, and to the fact that they result from an excessive for- 
mation and exfoliation of epidermis, among the cells of which inflamma- 
tory exudation and even the contents of the involved cutaneous glands are 
diffused in various proportions. The scales are sometimes white and glis- 
tening, like mother-of-pearl; sometimes yellow, and more or less waxy in 
appearance ; sometimes brown or black ; sometimes close and dense in tex- 
ture; sometimes friable and flaky, or even powdery. In some cases they 
form an extremely thin layer, in others they are a quarter of an inch or 
more in thickness ; and occasionally, where a virgin patch has been slowly 
enlarging, the accumulated scales on its surface assume the form of a limpet- 
shell. The general outline of the crust will necessarily be determined by 
that of the patch on which it is produced. 

The subjacent skin is always more or less distinctly congested and 
thickened; and generally, when the disease is in an aggravated form and 
has existed for some time, tends to get excoriated and fissured, and then 
to exude serum and blood, which, mingling with the squamae, form distinct 
scabs. 

The eruption of psoriasis is peculiarly liable to attack the extensor sur- 
faces of the knees and elbows. But it may occur on any part of the person 
though it is comparatively rare on the face, and still more rare on the palms 
and soles. The hairy scalp is a common seat of the disease. The nails 
also are not unfrequently involved, becoming thick, rough, and coarse in 
texture. It is very apt to be symmetrical. 

Psoriasis presents, as may be supposed from the above account, many 
varieties of character, some of which it may be useful to remember, if only 
for descriptive purposes. Thus, when it consists of an eruption of numer- 
ous small spots, it is called ' p. guttata;' when of small disks covered 
thickly with white scales, ' lepra alphoides' or ' alphos ;' when of rings, 
' /. vulgaris;' when of segments of circles which have coalesced with simi- 
lar segments of adjoining circles, ' I. gyrata;' and when of irregular patches 
occupying a large area, k p. diffusa.' 

The progress of psoriasis is occasionally remarkably acute ; thus, it will 
sometimes come out and become general in the course of a week, and dis- 
appear with almost equal suddenness at the end of two or three weeks. 
At other times, and much more commonly, it is a chronic malady; some- 
times persisting for years in two or three situations, as, for example, on the 
knee, or point of the elbow, and presenting periodical exacerbations in the 
spring or autumn ; sometimes occupying large tracts of surface persistently 
(p. inveterata} for many years, or for life. 

The general health of patients suffering from psoriasis is rarely materially 
or even obviously impaired. Occasionally, however, febrile symptoms at- 
tend its acuter manifestations, and sometimes debility and emaciation super- 
vene in the course of long-continued severe attacks. Yet the remarkable 
tendency of the eruption to break out simultaneously in corresponding situ- 
ations on both sides of the body, and its undoubtedly hereditary character 
together with the fact that an almost identical eruption attends the consti- 
tutional operation of the syphilitic virus, point very strongly to the depend- 
ence of psorias on constitutional causes. It may be added that its develop- 
ment and disappearance are often very manifestly influenced by constitutional 
modifications. Thus it occasionally shows itself only during pregnancy, 
disappearing with the birth of the child; and, on the other hand, those 
who are subject to it, may lose it entirely during the period of child-bearing. 
It is remarkable how little local discomfort, comparatively, psoriasis pro- 



\ 

ICTHYOSIS. 



291 



duces ; a little stiffness and a little itching are often the only inconveniences 
complained of. 

B. Pityriasis rubra — This term was applied by Willan to a variety of 
that form of pityriasis already briefly considered under the head of ery- 
thema. Hebra, and in this respect, we follow him, employs it to designate 
a specific form of skin disease, of rare occurrence, and having a close 
affinity with psoriasis. So far as is known, it appears to commence with 
universal congestion of the skin, soon followed by general tendency in the 
epidermic layer to separate in scales. Its progress is slow, and it is doubt- 
ful whether a cure is ever effected. The redness of the cutis, when once 
established, persists, but is attended with little thickening or discomfort; 
and the epidermis continues to desquamate, the scales, however, sometimes 
accumulating in considerable quantity. When fully developed, there is 
nothing except the history and progress of the malady to distinguish it 
from universally diffused psoriasis. Patients suffering from it remain appa- 
rently healthy in other respects for a long time ; but (according to Hebra) 
they ultimately emaciate, become cachectic, and sink from exhaustion. 

Treatment. — The local treatment of psoriasis consists, first of all, in the 
removal of the scales, which may be effected by warm baths or poultices, 
or by the thorough inunction of oil or ointments of various kinds ; and 
then in the application of special remedies, among which may be included 
iodine paint, nitrate of silver, strong solution or ointment of subacetate of 
lead, and especially tar ointment, or other equivalent empyreumatic prepa- 
rations. The persistent use of warm baths for several hours daily is often 
of great value. The constitutional treatment most generally resorted to 
is the exhibition of arsenic in small repeated doses. Tar is often admin- 
istered internally with the same object ; as also are tincture of cantharides r 
copaiba, iodide of potassium, and phosphorus. Tonics and cod-liver oil 
are occasionally useful. The disease, however, is very apt to resist all 
treatment ; and even when a cure seems to be effected, it is very often 
only apparent, and the result of the normal periodic retrogression of the 
malady. The treatment of pityriasis rubra may be conducted on the same 
principles as that of psoriasis. 



VI. ICHTHYOSIS. 

Description. — Under this term are included certain affections of the 
skin, characterized by dryness of the epidermis, with tendency to crack 
and scale, deficiency or absence of the sebaceous secretion, and more or 
less horny conversion of the epithelium of the sebaceous follicles. 

A. Ichthyosis simplex, or xeroderma, is the commonest variety of the 
affection. It is for the most part congenital, and its presence is generally 
first recognized by the parents during the first year or two of life, in con- 
sequence of the harshness and dryness of the general surface of the skin 
and the difficulty they experience in keeping certain parts of it, such as 
those covering the elbows and knees, in a cleanly condition. In quite 
young children, indeed, it only manifests itself by the characters just 
enumerated, and by the tendency of the epidermis to come away in flakes. 
As life advances, the condition of the skin becomes more characteristic. 
The affection is then seen to be general, but differing in severity in differ- 



292 



DISEASES OF THE SKIN. 



ent parts. It is least marked on the palms and soles, and on the inner 
aspects of the wrists, arms, and thighs. Here the skin may be a little 
dry only, and scarcely differing in appearance from healthy skin. The 
face is generally rough and dry, and slightly furfuraceous. But the greater 
part of the rest of the surface of the limbs and trunk is mapped out into 
irregular polygonal areae, the limits of which are, for the most part, deter- 
mined by the normal creases and folds ; and the epidermis of these arese 
— dry, hard, brittle, and somewhat nacreous, becoming partially separated 
at the edges, and sometimes undergoing complete separation — gives that 
scaly character to the surface which allies this disease anatomically -to 
psoriasis. But the places in which ichthyosis involves the most striking 
results are the knees, elbows, and those other parts of the surface which 
are naturally apt to get thickened under the influence of pressure or fric- 
tion. Here the epidermis becomes extremely thick and hard, generally 
brown, or black from impregnation with dirt, and divided even more man- 
ifestly than elsewhere into polygonal areos. Wilson states that in this 
affection many of the sebaceous glands are filled with a dry hard substance, 
which often projects from their orifices. 

A condition of skin very closely resembling ichthyosis is often met with 
in the course of chronic wasting diseases, such as phthisis, and is some- 
times developed with advancing years. 

Persons who suffer from ichthyosis are said to be, for the most part, 
feeble and emaciated. But that is certainly not a universal rule. They 
are often peculiarly liable to eczema and impetigo. 

B. Ichthyosis cornea is a much rarer affection than the last, and often 
arises at a later period of life. It is seldom general, but usually appears 
in scattered patches, which have a tendency to spread. It is characterized 
by the development of prominent hard, dry, horny processes of epidermis, 
which very often have an exact resemblance to those occupying the sur- 
face of the knee in the simple variety of the disease. These are usually 
grouped together, and hence individually often assume an irregular pris- 
matic form ; and they project sometimes a quarter of an inch or more above 
the general surface. They are partly due to a mere overgrowth of epider- 
mis in patches, corresponding to the normal polygonal area} of the skin ; 
but are mainly, we believe, connected with the horny conversion of the 
epidermic lining of the sebaceous follicles. In the latter case the horny 
outgrowth first appears as a comedo-like body, which distends the orifice 
of the follicle, and then rises above it in form not unlike a caraway seed. 
Presently this gets detached or broken, but the horny matter, still growing 
upwards and in breadth, distends the sebaceous follicle and its orifice more 
and more, until they form a mere shallow pit, surrounded by a tumid ring. 
With the progress of the disease, the pit is effaced ; what was the inner 
aspect of the follicle becomes level w r ith the surface of the skin or projects 
above it, and still produces (but now from a larger area) its horny growth. 
Finally, the tendency to horny development extends from the follicle to 
the epidermis immediately surrounding it. These bodies absorb dirt, and 
consequently become more or less opaque and black. They are often shed, 
and then occasionally leave the surface from which they sprang tolerably 
healthy. 

Treatment — The simple form of ichthyosis is incurable ; but it may be 
much benefited and rendered tolerable by cleanliness, frequent baths, and 
keeping the surface anointed with oil or grease — olive oil, neat's-foot oil, 
and the like. The horny variety also is uninfluenced by medicine. But 



ECZEMA. 



293 



it sometimes dies out in certain situations while it advances in others, and 
hence it is conceivable that it might occasionally subside altogether. But, 
although a cure is not to be expected, the horny growths may generally 
be removed, and the chief discomfort and offensiveness of the disease kept 
in abeyance, by the frequent use of warm baths, and application of poul- 
tices or oil. 



VII. ECZEMA. {Lichen. Strophulus.) 

Causation and description The first of these affections is vesicular, 

that is, characterized by the development of vesicles upon an inflamed 
base ; the second of them is generally regarded as papular — in other words, 
as due to the formation of solid pimples on an inflamed surface ; the last 
is simply the lichen of children. Many modern authorities, however, now 
regard the various forms of eczema and lichen as merely varieties of the 
same disease, and strophulus a fortiori as a variety of eczema. We adopt 
this view, and combine them in a common description under the general 
name of eczema. 

Eczema is an inflammation of the skin, for the most part much more 
acute in its phenomena than psoriasis, and attended with much more vio- 
lent local irritation. It often commences with itching ; but this is soon 
followed by the appearance of minute acuminated papules, which are more 
or less red from congestion, which may be either grouped in patches, or 
scattered, and which sometimes (but not by any means invariably) origin- 
ate at the points from which hairs emerge. The papules gradually in- 
crease in size, sometimes retaining the solid form, sometimes being obvi- 
ously vesicular almost from their first appearance. In the former case 
they may attain a line or more in diameter, when their acuminated cha- 
racter probably disappears ; but more frequently perhaps they reach the 
average size of a millet-seed ; and then, after they have remained out for 
a few days or a week or two, their redness fades, their surface desquamates, 
and they gradually subside. When the eruption is essentially vesicular, 
each papule (which is generally intensely inflamed) is occupied or crowned 
by a circumscribed accumulation of serum between the horny and the 
mucous layers of the epidermis. The vesicles are rarely larger than a 
poppy-seed, excepting when they are closely aggregated and neighboring 
ones coalesce ; under which circumstances a considerable area may get 
covered with a low undulating bleb, pinned down, as it were, here and 
there to the subjacent surface by the remains of the party-walls between 
adjoining vesicles. In this case, also, the eruption may subside at the 
end of a few days; but the appearances which attend its subsidence vary. 
Sometimes the contents of the vesicles become absorbed, and simple des- 
quamation follows. More commonly the vesicles burst ; and the exuded 
serum, mingling with the separating epidermis, coagulates into a scab, the 
character of which depends on a variety of circumstances — such as the 
part of the skin affected, the cessation or persistence of exudation, the 
entanglement in it of dirt or other foreign matters, and the admixture of 
blood or pus due to the effects of scratching or other local violence. In 
the simplest case the scab is often of a sulphur-yellow hue, and more or 
less powdery. More commonly perhaps it is of a dark color, scaly or 



294 



DISEASES OF THE SKIN. 



gummy, and adherent to the surface. On the scalp the crusts are apt to 
accumulate' and to form thick dirty laminae. 

Eczema is liable to become chronic. In some cases, especially in the 
papular form, the eruption then loses its vivid redness, and the surface gets 
thickened, rough, scurfy, and fissured. In some cases, and mainly such 
as are vesicular, large tracts of skin become red, excoriated and moist, 
and, on close examination, may be found to be covered in patches with a 
thin, opaque, soft, epidermic layer which is studded more or less abund- 
antly, especially at the edges, with pits (very much like the perforations 
by which postage-stamps are separated from one another), at the bottom 
of which a red weeping surface is visible. These pits are excoriations and 
correspond to vesicles ; and in such cases are probably the only representa- 
tives of vesicles which can be recognized. Again, even in vesicular cases, 
the inflamed surface often after a time loses its vesicular character, becomes 
uniformly inflamed, brittle and scaly, and assumes characters which, apart 
from the history of the case, are identical with those of chronic psoriasis 
or pityriasis rubra. 

The vesicles or papules of eczema may be either scattered and discrete, 
or collected into circular or oval groups of small size, or aggregated in 
larger irregular clusters, which tend to run together — the intervening skin 
being at the same time studded with isolated spots. In the first of these 
cases the papular form of the disease constitutes lichen simplex or strophu- 
lus intertinctus (red gown or red gum) ; in the second, lichen circum- 
scripta or strophulus volaticus; and in the third, lichen agrius, or stro- 
phulus confertus (rank red gum). Eczema may be acute or chronic — 
the former lasting for a week or ten days, or more ; the latter often con- 
sisting in successive outbreaks of the acute disease, but including those 
cases in which the skin assumes the features of psoriasis diffusa, and also 
the form commonly known as ''eczema rubrum.' In the last there is gene- 
ral excoriation with intense redness, abundant exudation of serum, and the 
formation of numerous red oozing points in place of distinct vesicles. It 
is most frequently seen in typical completeness on the lower extremities 
of elderly persons. 

No part of the surface of the body is free from liability to eczema. It 
attacks some parts preferentially, however, and then often receives a local 
epithet. Thus it frequently occurs upon the hairy scalp (e. capitis), con- 
stituting a very troublesome and chronic affection ; on and in the ears 
(e. aurium) ; at the edges of the eyelids (e. palpebrarum) ; and on the 
cheeks (e. faciei). It is common too in the axilla and bend of the elbow, 
about the anus, pubes, and outer part of the thigh, and in the bend of the 
knee. The nipples of suckling women and the umbilicus of the newly- 
born babe are frequently affected. And it is not uncommon on and be- 
tween the fingers. The affections known as ' grocers' itch,' ' bakers' itch,'' 
and warehousemen 's itch' are all of them eczema or lichen agrius of the 
backs of the hands and wrists. 

Not unfrequently, when the eczematous inflammation is severe, spots of 
suppuration appear intermingled with the original vesicles and papules ; 
and the scales which result are thicker and darker than those of simple 
eczema. Eczema then approximates in its characters to impetigo, and 
consequently is often termed 1 e. impetiginodes.' 

Eczema, in its various forms, is the most common of all skin diseases. 
It is of frequent occurrence in babes and young children ; but no age is 
exempt ; and it may break out for the first time in extreme old age. It 



ECZEMA. 



295 



is not an unfrequent attendant on pregnancy and lactation. It is some- 
times distinctly hereditary; and a previous attack generally predisposes to 
subsequent attacks. Its causes are not very obvious ; occasionally, however, 
it is clearly produced by local irritation — in the head by the constant use 
of hard brushes ; in the nipples by the irritation of sucking ; between the 
thighs and buttocks and analogous parts by the effects of the local secre- 
tions and by attrition ; and in bakers and others by the irritating sub- 
stances among which they work. Eczema is also frequently induced by 
the presence of scabies or pediculi. These, however, are not the only 
causes. It is often idiopathic, and is then not unfrequently preceded for 
a day or two by febrile symptoms. It is often ascribed to gout, dyspepsia, 
uterine complaints, teething, and the influence of weather and of climate. 

Excepting in the case of the extensive diffusion of the acute disease, 
eczema is rarely attended with constitutional symptoms. Locally it is 
characterized by the presence of more or less itching, tingling, or burning. 
The itching in some cases, indeed, is unbearable. 

Treatment. — There is no specific treatment for eczema ; it is therefore 
especially important in every case to ascertain if possible the cause on 
which it depends, or whether or not the patient have any associated malady 
affecting the general health ; and to treat it. Thus the constitutional treat- 
ment of eczema may resolve itself into the treatment of gout or indiges- 
tion ; the local treatment into the destruction of insects, or the cessation 
from certain kinds of manual labor. Alkalies, such as liquor potassse or 
the bicarbonate of potash or soda, in combination with vegetable tonics, 
are often resorted to. But the remedy on which most reliance is placed 
is arsenic. This is generally given in the same manner as in the treat- 
ment of psoriasis, and is by most physicians regarded as being most effica- 
cious in the chronic forms of the disease. When febrile symptoms are 
present, mild laxatives and cooling medicines are desirable. Tonics are 
often beneficial in its later stages. It is well to pay attention to the diet. 
Alcoholic drinks are generally injurious, as also are rich foods and hot con- 
diments. The local treatment must vary with the stage of the affection, 
its intensity, and extent. In the acute stage, and always when there is 
much inflammation, cold-water dressings or evaporating lotions, or even 
the cold douche continued from ten minutes to half an hour at a time, are 
very useful. Under the same circumstances lead-wash, and such-like ap- 
plications, are beneficial. At a later period, when there is much accumu- 
lation of scabs, it is important to remove them either by washing with soft 
soap and water, or poulticing, or the saturation of the part with olive-oil. 
Then the surface must be kept clean ; and mild mercurial ointments, or 
ointments containing lead or zinc, may be gently applied after each wash- 
ing. In the dry and scaly condition of eczema which simulates psoriasis, 
the treatment applicable to the latter affection may be employed. Hebra 
recommends for some cases the rubbing in of liquor potassse until it acts 
chemically on the diseased structures, for the purpose both of removing the 
morbid surface, and of promoting more healthy action. The caustic is 
applied once a week, the parts being treated with water-dressings in the 
intervals. Over limited areae of disease, the application of the solid nitrate 
of silver sometimes effects a cure. As a rule, however, we think that 
soothing local treatment, combined with cleanliness, will be found most 
efficacious. And although soap may be occasionally employed to aid in the 
removal of scabs, persistence in its use is generally injurious. The patient 
should use, instead of it, bran, oatmeal, starch, milk, or yolk of egg. 



296 



DISEASES OF THE SKIN. 



VIII. IMPETIGO. (Ecthyma.) 

Causation and description, — The affections comprised under these names 
are essentially pustular ; we regard them as being identical, and shall de- 
scribe them as varieties of impetigo. 

Impetigo is a disease which consists in the formation of pustules at the 
surface of the skin, either between the cutis vera and epidermis, or between 
the corneous layer of the epidermis and the rete mucosum. The develop- 
ment of pustules is generally attended with more intense inflammation 
than that of vesicles or papules ; and pustules are, for the most part, sur- 
rounded by well-marked congestive areolae, and situated upon more or less 
distinctly thickened bases. They occasionally commence in vesicles or 
papules, and thus eczema or lichen may pass into impetigo. Most com- 
monly, however, they originate in spots of inflammation — stigmata, papules, 
or tubercles — in which suppuration is manifest almost from the beginning. 
The pustules vary in size from that of a pin's head (or less) to that of a 
split pea or bean. They are generally round or oval in outline, but some- 
times irregular and angular, and project in the form of an oblate hemi- 
spheroid. At the end of a day or two they break, or their contents concrete, 
and scabs are formed, which are generally thicker and darker than those 
of* eczema; but which, nevertheless, vary very much in color and consist- 
ence, being sometimes sottish, translucent, and honey-like, sometimes dark, 
opaque, and tough. If the progress of the pustules be favorable, the scabs 
separate after a few days, leaving reddish spots behind them, which are 
soon effaced by the completion of a normal layer of epidermis. Very often, 
however, the scabs become detached while the subjacent surface is still 
secreting pus ; and not unfrequently, when the scab seems fully formed, 
suppuration still goes on beneath and around it, leading on the one hand 
to a deeper erosion of the skin, on the other hand to the lateral extension 
of the pustule by the gradual undermining of the surrounding epidermis 
and the incorporation of the successive circles of suppuration thus formed. 
In the latter cases the local progress of the disease may be maintained for 
a long time; and in these alone, but rarely even here, is there danger of 
the production of permanent cicatrices. The long continuance of impetigo 
sometimes leads to permanent harshness, muddiness, and deterioration of 
the skin. 

The lymphatic glands in relation with the part affected by the disease 
generally get inflamed, large and tender, and occasionally suppurate. 

The pustules of impetigo sometimes come out singly (i. sparser.), some- 
times in groups (i. Jigurata) ; and the groups may be of considerable 
extent. In the former case the pustules are generally larger than those 
of the grouped variety; and if the subjacent thickening and surrounding 
inflammation be considerable (as they are very apt to be when the pustules 
are seated on the buttocks or lower extremities, and in adults), the affection 
is often termed i ecthyma.'' In the latter case the congestion connected 
with the several adjoining pustules blends, and thus forms a common area 
of inflammation which is often very intense (*. erysipelatodes). The scabs 
also, under such circumstances, are apt to run together and form a con- 
tinuous mass or lamina (i. scabida). 

Impetigo occurs on all parts of the surface. It is common on the head 
and face, especially of young children, and when'' abundant and confluent 
in the latter situation is sometimes called ' porrigo larvalis.' Occasionally 



SUDAMINA. 



29t 



it attacks the hairy parts of a man's face, and then constitutes one variety 
of the affection termed ' sycosis.' It is then very intractable, owing pro- 
bably to the fact that the root-sheaths of the hairs are specially involved. 
It is met with frequently about the buttocks, and indeed on all parts of the 
trunk and extremities. 

Impetigo is liable to spread by inoculation : thus it may be conveyed 
from the child's head or face to the fingers with which it scratches itself ; 
or from the nursling's face to the mother's bosom or hands ; or, again, from 
child to child in families or schools. Sometimes it appears to originate 
idiopathically, and to be preceded by feverish symptoms, lasting for a day 
or two ; it may be a subsequent development of lichen ; and is very often 
produced by local irritation, arising from pedicula, acari, and even me- 
chanical causes. It is common during the period of dentition. The 
duration of impetigo is very various, depending partly on the cause, partly 
on the health of the patient, and partly upon hygienic conditions. The 
acute form may subside at the end of a week or two ; but the disease 
is very apt to be chronic, and kept up for months, and even years, by 
successive acute outbreaks. Those who have had previous attacks are 
liable to suffer from relapses. The constitutional symptoms are generally 
trivial ; there is often, however, some degree of fever when the affection 
is extensive and acute, especially if the lymphatic glands are implicated. 
There is generally some itching and tingling of the parts affected. 

Treatment. — The local treatment of impetigo differs but little from that 
of eczema. In quite the early stage the application of cold or tepid water, 
or cooling lotions, is useful. When scabs have formed it is always, im- 
portant to effect their removal, and this may be accomplished in the same 
way as in eczema. After their removal, the application of lead or zinc 
lotions, combined with glycerine, or of mild mercurial ointments, is gene- 
rally sufficient. Caustics are rarely beneficial, or even admissible. When 
the hairy parts are affected it is always well to have the hair cut short ; 
and in the case of sycosis it is generally necessary to resort to epilation. 
It is always important to treat any associated malady under which the 
patient is laboring, and which may be affecting his general health. But 
as a rule, tonics are indicated, especially iron, mineral acids, quinine and 
other vegetable bitters, and cod-liver oil. Change of air is often of great 
benefit. 



IX. SUDAMINA. MILIARIA. 

Description These names are employed to designate the minute vesi- 
cles which appear scattered over the surface of the chest, back, flanks, and 
sometimes upper arms and thighs of persons who are perspiring profusely, 
or more frequently perhaps of those who, having had a dry skin for some 
time, commence again to perspire. Thus we meet with them in rheuma- 
tism, pneumonia, and many fevers at the commencement of convalescence. 
They form at the orifices of the sweat-glands, and are due mainly to the 
imprisonment of minute drops of sweat by the horny layer of the cuticle. 
They are generally about as large as pins' heads, round or irregular in 
shape, containing a colorless acid fluid with leucocytes, and quite unat- 
tended with inflammation. They can be easily felt as small, prominent, 
hard bodies ; but very often escape the eye unless carefully looked for, and 



298 



DISEASES OF THE SKIN. 



then appear like minute drops of melted white wax. They end in branny 
desquamation. Occasionally their contents are opaline and of alkaline 
reaction, and each vesicle is surrounded by a narrow halo of congestion. 
It is to sudamina presenting these characters that the term ' miliaria' 1 is 
sometimes, but unnecessarily applied. iSo treatment is required. 



X. HERPES. PEMPHIGUS. {Pompholyx.) 

Causation and description Herpes and pemphigus are vesicular or 

bullous affections, yet there is a very close affinity between them and ery- 
thema, especially erythema multiforme; and indeed it is questionable 
whether it might not have been best to discuss them all under the same 
heading. Both herpes and pemphigus become developed upon erythema- 
tous patches; and not unfrequently these patches are papulate, discoid, 
circinate, gyrate, or marginate, and consequently the vesicular or bullous 
eruption assumes corresponding characters. Indeed, in no inconsiderable 
proportion of cases, erythema, herpes, and pemphigus represent simply 
successive stages of the same affection. Various causes have been assigned 
for herpes and pemphigus, and among them one which is of great interest 
— namely, some affection, probably irritative, of the sensory nerves. One 
species of herpes — herpes zoster — is, as we shall presently show, always 
limited to the area of distribution of some one or more of the nerves of 
common sensation, and usually attended with intense neuralgic pain ; and, 
moreover, erythematous, vesicular, and bullous eruptions are shown by 
various authors, and especially by Charcot, to be common accompaniments 
of pachymeningitis of the cord and of other conditions causing equivalent 
irritative effects in the cord or nerves connected with it. 

A. Herpes By this term we understand an affection characterized by 

the development of clustered vesicles, varying between the size of a small 
pin's head and that of a split pea, and seated on an erythematous base. A 
circumscribed area of redness, round, oval, or irregular in shape, first makes 
its appearance. This soon becomes thickly studded with papules, which 
speedily acquire a vesicular character, and in the course of twenty-four 
hours or less attain their full dimensions. The vesicles are very close-set, 
and not unfrequently run more or less together, so as sometimes to form 
large bulhe. Their contents are in the first instance limpid and pale ; but 
they often become dark from admixture with blood, or opaque and yellow 
in consequence of suppuration. After two or three days they begin to dry 
up, and then form thinnish dark-colored, or gummy scabs, which in a few 
days more become detached, leaving a whole but slightly reddened surface 
behind. There is always much heat and tingling or stinging during the 
earlier stages of the disease. Its total duration is rarely more than two 
or three weeks, and often considerably less. 

Several forms of herpes are enumerated by dermatologists. We proceed 
to discuss the more important of them : — 

1. Zona, or herpes zoster (shingles) This is the most important and 

striking affection of the group. It is characterized by the formation of 
clusters of vesicles on inflamed patches of various forms, and ranging from 
the size of the palm of the hand to that perhaps of a split pea. The clusters 
appear almost simultaneously, and irregularly scattered, over the area of 



HERPES. PEMPHIGUS. 299 

distribution of one of the cutaneous sensory nerves Hence they always 
occur within certain definite limits and on one side of the body only. In 
addition to the general characters of herpetic affections, zona is apt to be 
attended with certain special peculiarities. Thus it is often associated 
with severe neuralgic pains in the neighborhood of the part affected, which 
sometimes precede, sometimes accompany, and sometimes follow the cuta- 
neous eruption, and often last for many weeks ; and again the inflammation 
is apt to be intense and to penetrate deeply, and hence to be slow of dis- 
appearance and to leave permanent scars, and sometimes (especially in the 
old and weakly) to become gangrenous. 

The most frequent seat of zona is the chest or abdomen, where it takes 
the course of the cutaneous branches of one of the intercostal nerves. But 
it is not uncommon elsewhere, though it is very often then not recognized 
as zona. Von Barensprung enumerates nine varieties ; and it would be 
possible, but is not necessary, to enlarge their number ; they are as fol- 
lows : z. facialis, where the parts supplied by the fifth pair are affected, 
the surface of the conjunctiva being sometimes involved ; z. occipito-col- 
laris, following the distribution of the occipitalis minor, auricularis magnus, 
superficialis colli, and occipitalis major; z. cervico-subclavicularis, corre- 
sponding to the descending superficial branches of the cervical plexus 
(supra-sternal, supra-clavicular, and supra-acromian) ; z. cervico-brachialis, 
affecting surfaces supplied by branches of the brachial plexus — namely, 
the shoulder, upper arm, forearm, and hand; z. dorso-pectoralis, corre- 
sponding to the third, fourth, fifth, sixth, and seventh dorsal nerves; z. 
dorso-abdominalis, corresponding to the eighth, ninth, tenth, eleventh, and 
twelfth dorsal nerves ; z. lumbo-inguinalis, corresponding to the branches 
of the upper lumbar nerves, and extending from the loin to the linea alba, 
involving also the pubes and genital organs, the gluteal region, and outer 
aspect of the thigh ; z. lumbo-femoralis, corresponding to the cutaneous 
branches of the second, third, and fourth lumbar nerves, more especially 
the external cutaneous, genito-crural, anterior crural, and obturator, and 
affecting therefore mainly the anterior and lateral surfaces of the thigh and 
the inner aspect of the leg and foot ; and lastly, z. sacro-ischiaticus, which 
follows the cutaneous branches of the sacral plexus. 

Zona attacks persons of all ages, but chiefly, it is said, young adults. 
It is held by some to be most common in spring and autumn, and also 
to occur only once in a lifetime. It is questionable, however, whether 
either of these statements is true. Its connection with nervous irritation 
has been already referred to ; but nothing more in reference to its causa- 
tion is known. 

2. Herpes simplex. — This name may be conveniently used of those 
cases in which a group of vesicles or several such groups appear, so to 
speak, casually in some limited area, which then commonly gives a 
specific name to the affection. Thus, we have h. labialis, affecting the 
lips and neighboring parts ; h. palpebralis, the eyelids ; h. auricularis, 
the pinna of the ear; and h. prceputialis and pudendalis, respectively 
the prepuce and the labia. In these cases the patches of disease are 
identical in appearance and progress with those of zona. But there is 
nothing to indicate that they have any connection with sensory nerves. 
Moreover, some of them (especially h. labialis) are especially apt to 
attend an ordinary catarrh, and to come on in the course of acute pneu- 
monia. 

3. Herpes iris is the designation of an eruption of vesicles which arise 



300 



DISEASES OF THE SKIN. 



in series of concentric rings upon a gradually enlarging erythematous disk. 
It is most frequently observed on the backs of the hands and wrists, feet 
and ankles, but is sometimes much more generally distributed. 

4. Herpes circinatus is the name applied to an inflamed disk, which gradu- 
ally increases in size, and whose enlargement is accompanied by the forma- 
tion of a ring of vesicles at the circumference, while the centre for the most 
part gradually returns to a state of health. 

It is obvious, as we have already pointed out, that there is no essential 
difference between the last two varieties or between them and erythema 
multiforme; and that h. iris and h. circinatus are simply later phases of e. 
iris and e. circinatum. It may be added that intermediate papular condi- 
tions are sometimes observed, to which the names of lichen iris and 1. cir- 
cinatus might (unnecessarily indeed) be applied. 

It is important, hoAvever, to bear in -mind that the name 'herpes cir- 
cinatus' is often given to the specific eruptions of favus and ringworm, and 
that the multiform erythematous and vesicular affections which have just 
been considered (though not themselves parasitic) are very apt to be simu- 
lated by and confounded with these vegetable parasitic diseases. 

Lastly, cases are occasionally observed in which erythematous patches, 
irregular in form and size, appear almost simultaneously over the whole 
cutaneous surface, and become speedily covered with herpetic vesicles 
which tend to run together. The patches individually are like those of 
herpes zoster ; and, moreover, like herpetic patches generally, run through 
all their stages in a week or two ; but they differ from them in their wide 
distribution. 

Herpes iris, h. circinatus, and the form of herpes last described, resemble 
in their symptoms the corresponding forms of erythema multiforme. They 
are usually of trivial importance, but occasionally, when of extensive dis- 
tribution, are attended with much febrile disturbance. 

B. Pemphigus This term comprises most of those inflammatory affec- 
tions of the skin which are attended with the formation of bullas or blebs. 
These sometimes attain the size of a hen's or duck's egg, and are devel- 
oped on round, oval, sinuous, or irregular surfaces. But associated with 
such blebs, we often find single or grouped vesicles, no larger than those 
of herpes. Hence the blebs of pemphigus may be considered to vary be- 
tween these limits. There is nothing specific, however, in the formation 
of a bleb ; any patch of erythema, or other forms of inflammation, or of 
gangrene, may become studded with vesicles, and any number of contiguous 
vesicles may run together and form a common cavity. It follows almost 
necessarily that there is nothing specific in the conditions to which the term 
pemphigus is applied, and that the limits between them and affections re- 
ceiving other names are to a great extent arbitrary. 

Pemphigus is not unfrequently (as has been pointed out above) the 
fully-developed stage of herpes iris, h. circinatus. and other forms of gene- 
rally distributed herpes. The stages of the disease are then well marked 
— the first being the appearance of a disk, ring, or irregular patch of ery- 
thema ; the second, the formation of small vesicles, sometimes in a ring at 
the circumference, sometimes in the centre, sometimes generally over the 
surface ; and the third, the extension or blending of these vesicles and the 
evolution of a prominent bulla, the edges of which become, for the most 
part, conterminous with those of the erythematous redness. Owing to the 
coalescence of neighboring patches of erythema, neighboring bulla? may 
coalesce into sinuous or gyrate bullous bands several inches in length. 



HERPES. PEMPHIGUS. 



301 



Further, the eruption may be sparse or limited in extent, or it may be 
general and abundant. The full development of the disease may occupy 
three or four days, or more, but is often much more rapid. In cases of 
this kind it sometimes happens that extensive tracts of surface become 
erythematous and remain so for some considerable time, vesicles and bullae 
from time to time appearing here and there upon them. In other cases of 
pemphigus, the formation of bullae is almost coetaneous with the appearance 
of the erythema, which may then indeed escape recognition as a separate 
stage of the affection, both being preceded by violent itching, stinging, or 
burning. The bullae of pemphigus are generally plump and distended with 
a pale straw-colored serum, which, after a while, gets darker in tint or milky 
and opalescent. After a few days the contents begin to disappear by evapo- 
ration and absorption, or the bullae rupture and they escape. Then a thin 
dry pellicle, consisting of the epidermis which had been raised up and of 
coagulated exudation, forms upon the affected surface, and after a few days 
more becomes detached, leaving a sound but somewhat reddened area be- 
hind. Sometimes, especially if the part have been irritated by scratch- 
ing or otherwise, or if the general health of the patient be bad, the scab 
more resembles that of eczema or impetigo, probably re-forms after removal, 
and convalescence may be very much protracted. Ulceration or even gan- 
grene may ensue. 

As will be gathered from the foregoing account, pemphigus presents a 
good many varieties. Sometimes it is acute, its entire duration being 
comprised within a period of three or four weeks. More frequently it is 
chronic — chronic, however, in the sense in which urticaria evanida is 
chronic — that is, prolonged by successive acute attacks. It is then often 
termed p. vulgaris. Sometimes a single bulla breaks out suddenly, to be 
followed on its subsidence by a second, and then by a third, and so on 
(p. solitarius). A form of the disease, termed p. infantilis, is occasionally 
met with in newly-born children ; large bullae form on the neck, behind 
■the ears, on the buttocks, genitals, wrists, and other parts, and for the 
most part progress unfavorably, ending in suppuration, ulceration, and 
gangrene. A further variety is that called by Alibert p. foliaceus. It is 
characterized by the successive formation of bullae of small size, which are 
generally flat and flaccid, and the contents of which become more or less 
distinctly purulent, aud dry up into thick yellow flaky scabs. These on 
separation leave a deeply congested weeping surface. P. foliaceus is said 
to spread gradually until it occupies the entire surface of the body, and 
never to be cured. 

The causes of pemphigus are not clearly known. There is reason, how- 
ever, to believe that in some cases, especially in that of p. infantilis or 
when it occurs on the soles or palms, the origin is syphilitic. And, as we 
have already pointed out, it appears in some instances to be connected with 
affections of the spinal cord or sensory nerves. The symptoms which 
attend its progress vary. There is often some degree of fever — sometimes 
high fever, the temperature reaching 104° or 105° ; and when the affec- 
tion is much prolonged, debility and emaciation may ensue. This latter 
is especially the case in the foliaceous form. Newly-born children affected 
with pemphigus generally succumb speedily. In many cases the patient's 
health remains apparently unimpaired throughout the whole course of the 
malady. 

Treatment — Whatever its form may be, herpes seldom requires special 
treatment. Cooling lotions, simple ointments, and protection of the affected 



302 



DISEASES OF THE SKIN. 



parts against rubbing, include all the local measures that are usually 
necessary. The only important object to aim at in the treatment of zona 
is the relief of the severe neuralgic pain which is so often associated with 
it. For this various measures may be tried, such as the local application 
of blisters or other counter-irritants, the inunction of belladonna, or of 
aconitia ointment, or the use of leeches ; and, besides these, morphia or 
other sedatives administered by the mouth or hypodermically. 

The bullae of pemphigus require little local treatment. They may be 
punctured and their contents permitted to escape ; but it is unadvisable 
to allow the cuticular pellicles covering them to get detached. For this 
reason, among others, it may be necessary to protect the parts with simple 
ointments spread on lint. For internal treatment iodide of potassium and 
mercurial preparations should be employed when syphilis is suspected. 
Arsenic is much lauded by some. In most cases, however, tonics are 
sooner or later indicated. 



XL RUPIA. 

Causation and description Rupia is described as beginning with flat 

bullae, rarely, if ever, exceeding half an inch in diameter ; first containing 
clear serum ; then producing very thick greenish-brown or dark-colored 
scabs, and deep destructive ulceration. In some respects, therefore, the 
disease resembles pemphigus ; but it differs from all ordinary forms of 
pemphigus in the fact that its bullae are the result, not of superficial but of 
deep-seated disease. Rupia, indeed, is to be distinguished less by the 
occurrence of bullae than by the character of its post-bullous stages. The 
rupial bulla slowly increases in size, is surrounded by a halo of congestion, 
and seated on a slightly thickened base. A scab soon forms, but while it 
is forming the bulla spreads at its margin, and fresh matter, which also 
soon coagulates, is produced around and under the first formed scab. In 
this way the rupial sore increases in diameter, the scab increases in thick- 
ness and prominence, and the subjacent ulcer becomes deeper and deeper. 
The resulting scab is always very thick, but sometimes flat and flaky, 
something like an oyster-shell [r. simplex), sometimes conical, like a lim- 
pet-shell (r. prominens), sometimes irregular and rocky in form. On its 
removal, a fresh scab usually forms. Rupial ulcers are always deep and 
unhealthy-looking, and cause much destruction of tissue and permanent 
cicatrices. In some cases, and especially in children, the ulceration extends 
rapidly, assuming a phagedaenic character (r. escharotica), or becoming 
distinctly gangrenous, when it is sometimes termed pemphigus gangrce- 
nosus. Rupial sores are generally scattered and few in number, and are 
not limited to any particular part of the person. They are, perhaps, most 
common on the buttocks and lower extremities. 

Rupia rarely, if ever, occurs in persons who are not obviously weakly and 
cachectic, and most frequently in those who have previously had syphilis. 
Indeed, there is some reason for regarding true rupia as essentially a syphi- 
litic disease. 

Treatment — In the constitutional treatment of rupia, tonics of various 
kinds, iron, mineral acids, vegetable bitters, cod-liver oil, together with 
good diet and change of air, are all-important. Anti-venereal remedies 



SEBORRHEA. ACNE. 203 

must not, however, be forgotten, especially if there be a clear syphilitic 
history. For. local treatment, poultices are necessary to aid in the detach- 
ment of the scabs ; and the resulting ulcers must be treated not only with 
poultices but with stimulating or detergent ointments or washes, and even 
in some cases with undiluted caustics, such as nitrate of silver, nitric acid, 
acid nitrate of mercury, or other such agents. 



XII. SEBORRHCEA. ACNE. 

Causation and description, — By acne is meant an inflammatory affec- 
tion of the sebaceous glands, dependent on, or at all events connected with, 
retention of their secretory products. In most inflammations of the skin 
the sebaceous glands of the parts affected share in the inflammation; and 
always in acne there is more or less tendency for inflammation to extend 
from them to the contiguous structures. Hence, as might be supposed, 
acne occasionally (and especially in some of its forms) passes into other 
recognized varieties of inflammation of the skin. Further, inflammation 
of the sebaceous glands is sometimes attended, not with retention of secre- 
tion, but with increased production and flow, so that w r e may have an 
inflammation of them which is not acne. This is sometimes named ' se- 
borrhea.'' 

A. Seborrhoea The secretion of sebum in some persons is naturally 

exceedingly profuse, but it is not therefore morbid, and becomes seriously 
inconvenient only in the absence of scrupulous personal cleanliness. In 
some cases, however, an excessive production of sebum occurs over certain 
limited areas, attended with distinct hyperemia of the parts, and more or 
less obvious hypertrophy of the glands. The increased production is 
limited in fact to patches of distinct erythema. This affection is not un- 
frequent in the scalp and on the face, especially in children. The secre- 
tion is usually more solid than sebum should be, and with the superficial 
epidermis concretes into greasy flakes, which adhere to the surface. A 
condition is thus produced which differs little, and not essentially, from 
pityriasis of the same parts. More rarely the secretion is quite fluid, and 
may be seen, after cleansing the surface, to form a minute drop at each 
glandular orifice. This condition, which is occasionally observed on the 
cheek and nose, is apt to be chronic, and sometimes becomes permanent. 

B. Acne — The unnatural accumulation of sebaceous matter in the se- 
baceous glands is of extremely common occurrence. It may be met with 
in glands which are still patent, as well as in those whose mouths are ob- 
literated. In the former case the orifices are dilated and prominent, and 
occupied by the dirt-blackened superficial portions of the accumulated 
sebum, the whole of which may, by squeezing, be removed in the form of 
small, maggot-like bodies (coniedines). In the latter case no orifices 
generally are detectable, the sebum retains its normal yellowish hue, and 
concretes into hard, pearly, laminated masses. This condition was termed 
by Willan 4 strophulus aibidus.' A small incision is generally necessary 
for their removal. Sebaceous tumors or wens differ little except in size 
and the consistence of their contents from the bodies last named. 

When such accumulations of sebum are associated with inflammation of 
the parts immediately surrounding them, we have that condition present 



304 



DISEASES OF THE SKIN. 



to which the term ' acne' is generally applied. Acne, therefore, may 
occur in two forms. In the one, there is circumscribed inflammation, 
attended with induration, prominence, and duskiness of tint, but the cause 
of inflammation is rendered obvious by the fact that at the most prominent 
part of the tubercle there is a dilated sebaceous orifice, choked with the 
secretion of the gland. In the other form the orifice of the gland is un- 
distinguishable, the accumulation is deep-seated, inflammatory products 
are diffused around, beneath, and superficial to it, and thus an indurated 
congested prominent tubercle is produced, which yields on inspection no 
visible proof of its connection with sebaceous accumulation. The tubercles 
of acne vary in size, and are sometimes as large as a horse-bean. They 
often suppurate, but, especially in the latter form, suppurate very slowly, 
leading before they discharge their contents to a good deal of localized 
disorganization, and eventually to the production of permanent scars. 
Their contents are scanty but thick, and consist partly of sebaceous matter, 
partly of pus. 

Different forms of acne are described, of which the majority are mere 
varieties of the same condition, and are generally combined in various 
proportions in the same case. The term ' a. punctata' is often applied to 
that very common condition in which the sebum simply accumulates in 
the follicles, and leads by its accumulation to the production of a series of 
black-tipped papules. By ' a. simplex' is generally understood a. punctata 
associated Avith inflammation and suppuration — the papules being sur- 
rounded by congestion, and often going on to the formation of small 
superficial abscesses, which in a short time discharge their contents, and 
then after a few days, or a week or two, heal up. The name a. indurata 
is given to those cases which are marked by general enlargement and 
induration with dusky or livid discoloration, and slow deep-seated suppu- 
ration. It must be added that one form of sycosis is distinctly a. indurata 
of the hairy regions of the face. 

Any part in which sebaceous glands exist may be the seat of acne. But 
it is most common on the face, especially the forehead, cheeks, no3e, and 
chin; and on the trunk, mainly between the shoulders and on the chest. 
It rarely occurs in young children, excepting in the form of strophulus 
albidus. It is most common in both sexes about the period of puberty, 
and from that time onwards to two or three and twenty. It is frequently 
met with, however, and then especially in its indurated form, in persons of 
middle and even advanced age. The causes of acne are obscure. It is 
certain, however, that the tendency to it runs in families, and that it has 
a special connection with the period of development and maturation of the 
sexual functions. 

C. Acne rosacea — The condition to which this name is commonly given 
has been regarded by most modern authors as a mere variety of acne. 
Hebra, however, maintains that it is essentially distinct from acne, although 
frequently associated with it. It generally consists in more or less exten- 
sive patches of inflammatory redness, associated with slight infiltration of 
the affected cutis and visible dilatation of the superficial vessels, and also 
with the presence here and there upon the inflamed patches and in their 
neighborhood of tubercles corresponding precisely to the description already 
given of those of acne indurata. The affection is really therefore an in- 
flammatory condition of certain parts of the skin, in which there is a 
special tendency for the sebaceous glands to be implicated. Acne rosacea 
is limited to the face, affecting sometimes the nose, sometimes the cheeks, 



SEBORRHCEA. ACNE. 



305 



sometimes the forehead, sometimes the chin, but generally several of these 
regions at the same time. It is for the most part s} r mmetrical in its dis- 
tribution, and tends gradually to extend. It usually begins with circum- 
scribed hyperemia of the nose or cheeks, often attended with an increased 
secretion of sebacious matter, and generally with a more or less obvious 
development of dusky red tubercles, which may or may not suppurate. 
This condition, variable at first, soon becomes permanent, the cutis getting 
infiltrated and thickened, the small veins of the part dilated and tortuous, 
the tubercles more abundant and larger, and the face consequently much 
disfigured. In this latter state the disease may remain for many years, or 
for life, without, material change. But in some cases, and more especially 
in elderly men who have been addicted to alcoholic excess, the affection, 
which is then almost invariably limited to the nose and its immediate 
neighborhood, assumes a hypertrophic character; the parts which were 
originally affected with a simple form of acne rosacea become swollen and 
tuberculated, until in some instances the nose forms a huge misshapen, 
lobulated, pendulous mass. These changes are due to inflammatory hyper- 
plasia of the cutis vera, the tissues subjacent to it being rarely, if ever, 
implicated. The sebaceous glands, however, are involved and hypertro- 
phied, sometimes still discharging their products through the yet patent 
ducts, sometimes from obstruction allowing accumulation of sebum, and 
perhaps undergoing suppuration. The affected parts become deeply con- 
gested, and the dilated varicose veins larger and more numerous. 

Beyond heat and flushings, which are liable to frequent exacerbations, 
little local inconvenience or discomfort attends acne rosacea in any of its 
forms. 

Acne rosacea, in its simpler variety, is an affection of adult life, coming 
on generally between 25 and 30, but sometimes making its appearance for 
the first time after the age of 40. It is far more common in women than 
in men. The hypertrophic variety of the disease, on the other hand, is 
rarely observed in women ; and it attacks the opposite sex for the most 
part in middle age or the decline of life. The causes of hypertrophic 
acne rosacea are not in all cases obvious ; there is no doubt, however, that 
in large proportion it is traceable to long-continued habits of intemperance, 
or over-indulgence in spirituous liquors. The difficulty of assigning a 
cause to the other form of this affection is still greater; nevertheless, it is 
certain that many of those who suffer from it are dyspeptic or liable to 
uterine disturbances, and that when any of these complications are tempo- 
rarily present there almost invariably occurs marked exacerbation of the 
facial inflammation. 

Treatment. — In seborrhoea plentiful ablution with soap and water, and 
the use of astringent lotions, containing acetate of lead or sulphate of zinc, 
or of mercurial preparations, are the chief measure to be employed. Con- 
stitutional treatment is generally useless. 

In treating acne, it is of great importance to insist on frequent and 
thorough washing with soap and warm water, to be followed by the fric- 
tion of a rough soft towel, or flesh-brush. These measures-, however, are 
even more important to prevent than to cure. All black spots should be 
removed, either by squeezing the papules in which they are contained 
between the nails, or by pressing down upon them a ring, a little larger 
than the black spot, and including it. The mouth of a watch-key answers 
the purpose very well. Superficial collections of matter should be punc- 
tured, and discharged. The chronic tubercles of acne indurata should be 
20 



306 



DISEASES OF THE SKIN. 



opened with a narrow-bladed knife, and have their contents expressed, or 
should be touched at the summit with the acid nitrate of mercury, or some 
other equivalent escharotic. The local inflammation may be allayed to 
some extent by the use of lead-wash, or lotions containing from two to 
four grains of sulphate of zinc, or from half a grain to two, three, or even 
four grains of bichloride of mercury to the ounce. Mild mercurial oint- 
ments are sometimes useful. Sulphur, in the form of ointment or lotion, 
is strongly recommended by most dermatologists. In our general treat- 
ment we can aim only at improving the general health, and must be guided, 
therefore, solely by the general symptoms which the patient presents. 

In sycosis it is important to have the hair of the affected parts kept 
closely cut, and to remove the hairs running through the tubercles or pus- 
tules by frequently repeated epilation. Hebra insists on the necessity for 
keeping the surface constantly shorn, for the application of sulphur and 
other stimulating ointments, and for the incision of the inflamed tubercles. 

The treatment of acne rosacea differs little from that of simple acne. 
But it is especially important here to attend to the general health and 
habits of the patient, to remedy indigestion, to remove anaemia, to prescribe 
a wholesome unstimulating diet, and to maintain the healthy functions of 
the skin and other organs. The local treatment is absolutely that of acne 
simplex ; but it generally needs more persistent employment. 



XIII. LUPUS. {Noli me tangere.) 

Causation and description The term ' lupus' is applied to a series of 

affections characterized by a specific overgrowth of the cutis, for the most 
part of chronic progress, and resulting in the formation of indelible cica- 
trices, or in more or less extensive destruction of tissue. 

Lupus usually commences with more or less distinct congestion and 
hypertrophy of a limited area, which, in a large proportion of cases, is 
studded with solitary or grouped lenticular tubercles a line or two in 
diameter, and presenting a slightly translucent aspect and a dull red or 
pale salmon color. The patch of congestion slowly increases in area or 
the tubercles in number, until in many cases a large extent of surface 
after a while becomes involved. While this extension is in progress vari- 
ous changes take place. In some instances, the parts first implicated, 
without attaining any further stage of development, gradually lose their 
inflamed and hypertrophic character, but instead of simply reverting to 
the healthy condition, become pale, depressed, and contracted, and assume 
a cicatricial character. In some instances, previously to the attainment 
of this cicatricial termination, their surface yields adherent scales, or 
crusts. In some, the tubercles almost from the beginning, are the seat of 
suppuration, and become crowned with thick adherent scabs. In some, 
extensive ulceration ensues, Avith grievous and irremediable destruction of 
parts. In its morbid anatomy lupus appears to consist in the development 
of a kind of tissue, resembling granulation tissue, composed of small cells, 
imbedded, according to the density of the growth, in a greater or smaller 
quantity of fibrous material. Lupus is generally regarded as a scrofulous 
disease ; and it not unfrequently occurs in those who are suffering or have 
suffered from scrofulous suppuration of the cervical glands, or who are 



LUPUS. 



307 



otherwise out of health ; moreover exacerbations seem not unfrequently 
to be induced, in those who are already its subjects, by temporary condi- 
tions of general ill-health. Females suffer from lupus much more fre- 
quently than males, children than adults, and the poor than the well-to-do. 
The local symptoms which attend its progress are for the most part trivial ; 
often the patient makes no complaint, or, if he complains at all, complains 
only of itching or tingling. 

In accordance with the different peculiarities of character and progress 
which have been above referred to, several varieties of lupus have been 
described, the more important of which we shall now briefly discuss. 

A. Lupus erythematosus, which was first described and named by 
Alibert, is the least severe form of the disease. It occurs mainly on the 
cheeks, nose, forehead, and scalp, but is not limited to these parts ; and it 
makes its appearance there in the form of rounded erythematous patches, 
which slowly increase in diameter, and may at first be readily mistaken 
for patches of simple erythema. But sooner or later they get covered with 
either thin scales or thick crusts, composed largely of sebaceous matter 
and continuous by their under surfaces with processes of the same material 
prolonged into the dilated orifices of the subjacent sebaceous glands. In 
the former case the affection simulates psoriasis ; in the latter, that morbid 
condition of the knuckles caused by dissection, to which Dr. Wilks has 
given the name of 4 verruca necrogenica.'' The progress of lupus erythe- 
matosus is very chronic, and scarcely attended with any abnormal sensa- 
tions, but when it subsides it leaves behind it permanent changes in the 
condition of the skin. It usually begins in adult life, and affects women 
more commonly than men. 

B. Lupus exedens and non-exedens {tubercular lupus) — Lupus non- 
exedens, like the last, may occur on any part of the surface of the body, 
but usually originates on the nose or cheek. It commences with the 
appearance of small tubercles, such as have been above described ; which 
slowly increase in number, sometimes assuming an annular arrangement, 
and involve more and more of the contiguous cutaneous surface, some- 
times extending to the mucous membranes, and especially to that of the 
nose. Their course is very uncertain. Sometimes, after making but 
little progress, they slowly subside. More frequently they advance irregu- 
larly, now remaining quiescent for a while, now undergoing comparatively 
rapid extension, and thus, continuing for years, ultimately involve exten- 
sive tracts of skin. These become seamed and puckered, and of a grayish- 
white color in those parts which have undergone involution, and present 
groups of reddish tubercles in those which are still extending. In the 
progress of tubercular lupus, the tubercles not unfrequently become covered 
with scales or crusts, below which gradual erosion is going on, or undergo 
actual suppuration or ulceration with the formation of scabs. In some 
cases the tendency to suppurate or ulcerate, and to scab, forms a special 
feature in the disease, which then receives the name of 1 lupus exedens.' 
This leads to more or less rapid and extensive destruction of tissue, and 
when occurring (as it most frequently does), in connection with the nose, 
often involves the gradual loss of more or less of the septum nasi and car- 
tilages which bound the nostrils. The cicatrization to w r hich lupus non- 
exedens, and still more that to which the exedent form leads, is not merely 
in a high degree disfiguring, but often induces serious consequences. The 
eyelids become retracted, the nose curiously thin and pointed, the alae con- 
tracted and the nostrils altered in shape, the mouth distorted, and the 



308 



DISEASES OF THE SKIN. 



lower lip and chin drawn down upon the chest, as they sometimes are 
after extensive burns. The forms of lupus here described usually begin 
in early life, but are often prolonged by successive outbreaks up to an 
advanced age. 

C. Pustular lupus. — This variety of the disease simulates impetigo. It 
is sometimes limited to the face, and has then been termed by Mr. Startin 
' impetiginous lupus.' Sometimes, however, the whole surface — head, face, 
trunk, limbs — becomes more or less thickly covered with it. The erup- 
tion consists of tubercles, which are mostly discrete, but are here and there 
collected into confluent patches, which vary from J to J inch in diameter, 
tend to suppurate scantily at their most prominent points, and presently 
become crowned with small dark, hard scabs, deeply imbedded, and re- 
maining fixed (unless detached by violence) for weeks or months. The 
detachment of one scab is liable to be followed by the formation of another ; 
but sooner or later each tubercle gets absorbed, leaving behind it a tem- 
porary livid discoloration and a permanent depressed cicatrix. Pustular 
lupus is often associated with the presence of suppurating scrofulous glands. 

Treatment In the treatment of lupus, constitutional remedies hold an 

important place. Among these the most efficacious are cod-liver oil, qui- 
nine, iron, and other forms of vegetable and mineral tonics, and arsenic. 
If there be a suspicion of syphilis (and it is often extremely difficult to 
distinguish non-specific lupus from some forms of tubercular syphilide) the 
ordinary anti-syphilitic remedies must not be omitted.' Change of air is 
often valuable. Local remedies are very variable in their effects ; some- 
times they seem to do more harm than good, sometimes their use appears to 
be followed by rapid amendment. In the tubercular form of the disease, 
especially if the tubercles be attended with ulceration or any other form of 
destructive process, the use of solid nitrate of silver, potassa f'usa, acid 
nitrate of mercury, or arsenical paste (made according to Mr. Startin's 
formula with three parts of arsenious acid, two parts of bisulphuret of mer- 
cury, and one part of calomel, together with water) is often highly advan- 
tageous. The caustic, however, needs to be repeated from time to time, 
and previous to its application the surface should be freed from scales and 
scabs. In the milder cases less severe local applications are usually indi- 
cated, such as nitric acid lotion, iodine paint, blistering fluids, or mercu- 
rial, lead, or zinc ointment. 



XIV. KELOID. (Kelts.) 

Causation and description This affection was first described and named 

by Alibert. It is characterized by the gradual formation of roundish, 
elongated, linear, branching, or reticulate patches, which are elevated a 
line or two, or even more than that, above the general surface, and appear 
to be mainly a hypertrophic condition of the cutis. The patches vary in 
color, but are usually either white and shining, or of a more or less rosy 
hue, and are often marked with vascular ramifications. They present for 
the most part a smooth and rounded surface, and generally send out here 
and there claw-like processes or spurs which gradually lose themselves in 
the surrounding healthy skin. It is from this peculiarity that their name 
was derived, and that they acquire their generally recognized resemblance 



XANTHOMA. 



309 



to hypertrophic scars. They are dense and firm in consistence, and never 
become covered with scales or crusts, or undergo ulceration or other such 
destructive changes. They are sometimes attended with tingling, itching, 
or burning, and are often tender to the pressure. Their progress is slow ; 
they usually extend gradually for a time, and then are apt to become sta- 
tionary ; occasionally they undergo involution, and disappear. In the early 
stage of their development they consist largely of fusiform cells, and are by 
Virchow and others regarded as sarcomatous; at a later stage they become 
almost entirely fibrous. 

Keloid commonly occurs in isolated patches of various sizes on the chest 
or back ; but it may be multiple, and may be met with on any part of the 
surface, even the face, ears, genital organs, and extremities. Occasionally 
it involves nearly the whole of the trunk. 

The causes of the disease have not been clearly determined. It occurs, 
however, mainly in adults, and seems not unfrequently to be induced by 
local irritation or injury. Indeed, one form of it, which is generally termed 
'false keloid,' seems to be clearly due to hypertrophic changes occurring 
in connection with ordinary scars. 

The treatment of the disease is unsatisfactory. The growths, when 
large, have occasionally been removed with the knife, but the results have 
not been encouraging. Local applications, such as iodine paint, blistering 
fluid, and various forms of stimulating ointments, have been tried and re- 
commended ; but, again, the benefit resulting from them has rarely been 
very decided. 



XV. XANTHOMA. ( Vitiligoidea. Xanthelasma.) 

Causation and description This affection was first clearly described 

by Drs. Addison and Gull under the second of the names given above. 
It has since been carefully investigated and described by various derma- 
tologists, and more especially by Dr. Hilton Fagge. It consists mainly in 
a kind of fatty or atheromatous change in the texture of certain portions 
of the skin, and in this respect has a very close affinity to atheroma of the 
arteries. The affected parts appear on section to consist of fibrous tissue 
(in a greater or less degree the normal fibrous tissue of the part) studded 
more or less abundantly with groups of oil-globules. It occurs in two 
forms, namely x. planum and x. tuberosum. In the former, the affected 
portions of the skin present an opaque, yellow, or buff color, are distinctly 
marginated, and although perhaps appearing to be elevated, are actually 
level with the general surface and undistinguishable from it in consistence 
and texture. In the latter variety, papules or tubera arise varying from 
the size of a pin's head to that of a hazel-nut, which sometimes by their 
aggregation form nodulated masses of considerable extent. These are 
generally yielding, elastic and but little indurated, are of the normal color 
of the skin or of a reddish hue, and frequently studded, especially in their 
more prominent parts, with opaque yellow spots. Xanthoma is often un- 
attended with local uneasiness ; in the tubercular form, however, there is 
not unfrequently some degree of itching or tingling, and tenderness. Its 
course is for the most part progressive ; but sometimes it becomes stationary 
and occasionally disappears. It never undergoes ulceration or other such 
destructive changes. 



310 



DISEASES OF THE SKIN. 



Xanthoma may occur on almost any part of the surface ; on the eyelids, 
nose, ears, cheeks, head, neck, shoulders, nates, back of elbows, and front 
of knees, about the wrists and ankles, on the palms and soles, and on the 
knuckles of the fingers and toes. When occurring in the neighborhood 
of joints it seems to be not unfrequently distinctly connected with the 
tendons. Xanthoma has also been observed in the mucous membrane of 
the nose, gums, lips, tongue, and larynx. The plane form of the disease 
is met with mainly in connection with the eyelids, ears, and other parts 
of the face, and with the mucous membranes. This, if the affection be 
at all largely distributed, occurs concurrently with the tuberose form ; 
but it is not unfrequently alone present and limited to the face, and more 
particularly to the eyelids. In the latter case it usually commences in 
the skin of the upper lid near the internal canthus, and not unfrequently 
gradually extends thence until it involves the greater part of both lids. 
The tuberose form may be met with in the same situation, but is more 
commonly observed upon the extremities. When occurring in the palms 
or soles, the tubercles are usually of small size, but very numerous, and 
give a mottled aspect to the affected surface ; and on the wrists and ankles 
the affection may assume a good deal of the typical appearance of keloid. 

Although the causes of xanthoma, like those of so many other affections, 
are obscure, some curious facts have been observed which seem to have 
some relation with its etiology. Many recorded cases, probably half, have 
labored during the development of the disease under jaundice, due to 
organic disease of the liver; and many also, as Mr. Hutchinson has pointed 
out, appear to have suffered largely from sick headache. [Some recent 
observations seem to show that there exists in certain families a hereditary 
predisposition to the plane form of this disease. It occurs, no matter what 
form it assumes, much more frequently in women than in men.] In one 
or two cases the disease has been associated with diabetes. 

Treatment No efficacious treatment is known. 



XVI. LICHEN RUBER. 

Description. — This is the name given by Hebra to an affection which 
is to some extent, no doubt, papular, but has no affinity whatever with 
the eruption commonly included under the name of lichen. It begins 
with small colorless or reddish solid papules, for the most part unattended 
with itching. These increase in number, but very little in size, and pre- 
sently coalesce at their margins so as to form smooth patches of uniform 
thickness and induration, the effect of which is to smooth away the finer 
furrows or creasings of the skin, to interfere with the free movement of 
parts, and to render the patient more or less hide-bound. The indurated 
skin is often thickened apparently to two or three times its normal thick- 
ness, and it loses its sensibility in a greater or less degree. 

The disease begins symmetrically on different parts of the body, and 
may remain limited in its range, or may gradually spread over the whole 
surface. But there are certain situations in which its effects, however 
wide its distribution, are most obvious : these are the hands, feet, face, and 
neck. The hands are affected mainly on their palmar aspects, but the 
convex surfaces of the metacarpophalangeal and phalangeal joints are 



SCLERODERMA. 



311 



also involved, and, in a less degree, the remainder of the backs of the 
fingers, which are apt to remain papular. The hands get stiff and almost 
useless, the fingers are kept widely separated and semiflexed, and cracks 
are apt to appear over the convexities of the joints. The feet and toes 
are similarly affected. The skin of the face becomes smooth and hard, 
the delicate wrinkles about the eyelids, forehead, and cheeks undergo more 
or less complete obliteration, and much of the patient's mobility of features 
and natural expression is lost. The primary papules .and the infiltrated 
skin are said by Hebra to be red, and to have a tendency to yield thin 
scales. They are, however, sometimes pale, or of a pale dead-leaf color, and 
free, or almost free, from desquamation. Hebra points out, also, that the 
nails get brittle, and either thin or thick ; that the hair is unaffected ; that 
the disease rarely undergoes amendment or cure ; and that the patient 
tends to emaciate, and in the course of years to die from exhaustion. 
He further states that the papillae of the skin have been found after death 
to be hypertrophied, and the root-sheaths of the hairs thickened. 

Treatment Arsenic in large doses, and cod-liver oil by inunction, are 

the only remedies which have been found beneficial. 



XVII. SCLERODERMA. (Scleriasis. Addison's keloid. Morphcea.) 

Causation and description Under "the above series of designations 

have been described a number of morbid conditions of the skin, which are 
now generally admitted to be closely correlated, if not absolutely identical 
with one another. They are very rare, and consequently, although inter- 
esting, do not claim any lengthened consideration. 

They are all characterized by the appearance of patches of induration 
and thickening ; which vary in extent and shape ; tend gradually to increase 
in size ; are attended often with tingling, sometimes with anaesthesia ; are 
white and ivory-like, or of a pale yellowish or brown hue, sometimes 
mottled, sometimes surrounded by a halo of congestion or discoloration ; 
are for the most part of long duration, and in their progress apt to become 
faintly tubercular, or to desquamate, or even to ulcerate, and, when they 
finally disappear, to leave behind them more or less brownish discoloration, 
with atrophy and cicatricial seaming of the surface. The affected parts 
are for the most part smooth, scarcely, if at all, elevated above the general 
level, and incapable of being pinched up in a fold ; and the thickening, 
although generally limited to the skin, sometimes involves also the sub- 
jacent connective tissue. The affection appears to consist anatomically in 
an overgrowth of dense connective tissue, associated with the accumulation 
of cells, resembling lymph cells, in the sheaths of the small vessels. 

A. It is comparatively not uncommon to meet with a patch or group of 
patches of scleroderma on one side of the forehead, in the area of distri- 
bution of the fifth pair. The affection then usually remains limited to this 
region. It commences insidiously, perhaps as a mere discoloration, grad- 
ually increases in size, and occasionally spreads to the hairy scalp, where 
it causes circumscribed alopecia. It is very chronic in its progress. 

B. Another variety of the affection — Dr. Fagge's ' circumscribed scleri- 
asis' (scleroma) — is that which Dr. Addison described under the name of 
6 true keloid,'' deriving the work keloid from xytis (a spot produced, as it 



312 



DISEASES OF THE SKIN. 



were, by burning). In this, which is also a very chronic affection, the 
patches commence variously, sometimes as a mere loss or change of color, 
sometimes as a mere depressed smoothness, sometimes as a simple indu- 
ration, attended or unattended with itching or tingling. The patches 
differ in shape : are round, oval, band-like, irregularly polygonal or stel- 
late, and not unfrequently send out promontories, as it were, or peninsulas, 
into the surrounding healthy skin. They vary also in size : are sometimes 
no larger than a sixpenny-piece or shilling, but tend to increase, and thus 
sometimes involve ultimately very extensive arese. They are usually 
multiple, and new spots are apt to arise from time to time. Beyond the 
itching and tingling, the main source of discomfort to the patient is the 
interference with the free use of parts which any considerable extension 
of the disease involves. He becomes hide-bound, and his fingers, hands, 
arms, or other parts which are affected, more or less distorted, fixed, and 
useless. This immobility is increased when (as often happens) the skin 
becomes adherent to the subjacent tissues, and when (as also occasionally 
takes place) subjacent muscles waste. The mucous membrane of the 
tongue, lips, and gums is sometimes involved in the disease. 

C. A third form of the disease, which Dr. Fagge designates ' diffused 
scleriasis' (scleroma), is that to which the names 'sclerema,' 'scleroma,' 
'scleriasis,' and the like, are more particularly given. It appears to have 
been observed almost exclusively on the Continent, and is mainly charac- 
terized by the rapid extension of scleroderma over large parts of the surface 
of the body. It seems frequently to have begun at the back of the neck, 
and thence to have spread to the face, back and front of the trunk, arms, 
and even over the whole surface. The tongue may be involved. The 
integument becomes thick, hard, ivory -like, and smooth; the arms, hands, 
and fingers stiff and immovable; the face an expressionless mask. The 
aspect and feel of the affected regions have been likened to those of a 
frozen corpse. 

None of the above varieties of scleroderma appears to be associated with 
any indications of constitutional suffering; and the secretion from the kid- 
neys and even that from the affected portions of skin remain normal. 
They are all more or less chronic in their course — the first two lasting, as 
a rule, for years, and leaving on their subsidence marked signs of their 
pre-existence behind, the last, however, often disappearing entirely in the 
course of a few months. Women appear to suffer much more frequently 
than men. In some cases (especially of the diffused form, the attack is 
said to have originated in exposure to cold or wet ; but little or nothing 
further is known with respect to the causation of the disease. There is 
some obvious resemblance between scleroderma and the later stages of 
lichen ruber, and still more between it and true leprosy, of which disease 
some authors regard its circumscribed forms as mere varieties. 

Treatment — No local measures seem to have been useful in the treat- 
ment of scleroderma. The constitutional remedies which have been em- 
ployed include cod-liver oil, quinine, iron, arsenic, and iodide of potassium. 



ELEPHANTIASIS. 



313 



XVIII. ELEPHANTIASIS. (Elephas. Pachydermia. 
Barbadoes Leg. E. Arabum.) 

Causation and description. — The condition to which the above names 
have generally been given is mainly a disease of tropical climates, and 
more especially of certain parts of India. Its chief characteristic is a more 
or less enormous hypertrophy of the connective tissue of certain parts of 
the body, associated with early implication of the lymphatic glands and 
vessels. 

A. Elephantiasis commences with an erysipelatoid inflammation of the 
part about to become permanently affected, attended with febrile symptoms, 
and indicated by superficial redness, and general and deep infiltration. At 
the same time the superficial veins and lymphatics generally form red 
painful indurated cords, and the corresponding lymphatic glands undergo 
considerable acute tumefaction. If an incision be made at this time, a 
large quantity of yellowish transparent fluid, coagulating spontaneously, 
and having all the characters of lymph, escapes. After a few days, pro- 
bably, the inflammation subsides, but more or less swelling remains. Sub- 
sequent attacks of inflammation, excited by various causes, supervene at 
irregular intervals — each attack adding to the mischief, and leaving behind 
it a tendency to still further hypertrophic change. The final result is that 
the affected part becomes largely, sometimes enormously, increased in bulk, 
and altered in aspect. 

In some cases the hypertrophic condition occupies mainly the skin and 
subcutaneous connective tissue ; in some it involves the whole extent of 
connective tissue between the skin and bone. In either case, but chiefly 
in the former, the skin is liable to be much modified in texture and form ; 
sometimes it becomes coarsely papular or warty, sometimes studded with 
nodular elevations, sometimes undergoes ulceration ; and the epidermis, 
though often remaining normal, may desquamate, or get thick or horny, 
or acquire the characters observed in ichthyosis, or become more or less 
deeply colored from deposit of pigment granules in the rete mucosum. 
The affected surface, moreover, may be anaemic, congested, or livid. When 
the disease extends deeply, fat, muscles, and nerves get compressed and 
waste, but the bones undergo hypertrophy — new layers and irregular out- 
growths forming, by means of which adjoining bones occasionally become 
organically united. 

Elephantiasis appears to consist primarily in an inflammatory hyperplasia 
of the cellular elements of the connective tissue, in connection with which 
(according to Virchow) there is reason to believe that the roots of the 
lymphatic vessels are specially involved. Inflammatory overgrowth of the 
elements of the lymphatic glands next ensues, with obstruction to the 
passage of lymph through them. Then this fluid stagnates in the lymph- 
atic vessels, which sometimes dilate even to their radicles in the cutaneous 
papillae; and it presently accumulates in the interstices of the affected 
tissues, adding to their bulk and at the same time stimulating them to 
overgrowth. It is only in the early stage of the disease that the dilated 
condition of the lymphatics admits of ready detection. At a late period 
the morbid tissues are characterized mainly by the presence of a dense 
accumulation of white fibrous tissue. The lymphatic glands also, after a 
time, become the seat of fibroid change. 

The regions most frequently attacked with elephantiasis are the lower 



314 



DISEASES OF THE SKIN. 



extremities and genital organs. But other parts may become affected, and 
especially the female breast. In the first of these cases the disease may 
commence in the toes or about the ankle, and gradually involve the whole 
leg up to the knee. It rarely, however, rises above that point. In ex- 
treme cases the form and appearance of the affected member remind one 
of those of an elephant's leg, whence the common name of the disease. 
When the scrotum or labia are involved they often reach enormous dimen- 
sions; the scrotum, which is sometimes also the seat of hydrocele, may 
attain a weight of 50 or even 100 lbs. 

Elephantiasis is a disease mainly of adult life, and is more common in 
men than women. Its progress is slow, but is largely governed by the 
conditions under which the patient lives, or the care he takes of himself. 
Fatigue, exposure to weather, or of the affected part to anything provoca- 
tive of irritation or inflammation, is apt to aggravate it ; while, under oppo- 
site conditions, the disease may make but little progress, or remain station- 
ary. There is nothing in it necessarily inimical to life; but want of 
cleanliness or other accidental circumstances may give rise to ulceration 
or gangrene, and thus imperil life or cut it short. 

Elephantiasis does not appear to be a specific disease. Swellings and 
indurations of precisely the same kind are apt to occur in the vicinity of 
old ulcers, and especially in parts which have undergone repeated attacks 
of erysipelatous inflammation. Only in these cases the hypertrophy rarely, 
if ever, goes on to that inordinate extent which characterizes the endemic 
elephantiasis of tropical countries. 

B. Elephantiasis lymphangiectodes A condition, closely related to 

elephantiasis, occasionally arises independently of inflammation, at all 
events of inflammation of the parts chiefly implicated. It is due sometimes 
to the continued application of a tight ligature round the upper part of one 
of the extremities, sometimes to obstructive disease in the lymphatic glands,- 
or lymphatic vessels, either arising during adult life, or of congenital or 
infantile origin. In all of these cases the morbid condition appears to be 
chiefly, if not wholly, due to obstruction of lymphatics, with consequent 
dilatation of those below the seat of obstruction, accumulation of lymph in 
the textures, and overgrowth of the connective and other tissues. The 
lesions closely resemble those of elephantiasis Arabum ; and the resemblance 
is not unfrequently enhanced by the occasional supervention of attacks of 
inflammation. The disease appears to be not uncommon in tropical climates; 
and is attributed by Dr. Lewis to the presence of filarise in the blood, and 
to obstruction of the lymphatics by these entozoa. 

This form of elephantiasis generally first reveals itself by simple increase 
in bulk of the part affected. This increase goes on more or less insidi- 
ously, until it become considerable — the tissues getting more or less indu- 
rated and dense, and the surface pale, congested, or otherwise modified in 
color, and either smooth, papular, or tuberculated. After a time, groups 
of vesicles generally make their appearance, sometimes Avidely distributed, 
sometimes in an irregular patch, sometimes in a linear series, and gene- 
rally imbedded, as it were, in the solid tissue. These, which are really 
dilated lymphatic spaces, are apt to rupture from time to time, and then to 
exude considerable quantities — sometimes several pints — of lymph, which 
coagulates after its escape, and is either yellowish and transparent, or 
milky from the presence of molecular fat. This affection is usually limited 
to one of the lower extremities, or to the upper part of the thigh and con- 
tiguous part of the abdomen, or to the genital organs and perinasum ; and 



MOLLUSCUM CONTAGIOSUM. 



315 



it may be added that there is good reason to believe (as is elsewhere 
pointed out) that chyluria is due to a similar condition involving the 
mucous membrane of the bladder or other parts of the urinary tract. 
When the lower extremity becomes affected in infancy, not only does the 
limb increase generally in bulk, but the bones, relatively to those of the 
opposite member, become manifestly hypertrophied — augmented both in 
thickness and in length. 

Treatment The treatment of elephantiasis should be mainly prophy- 
lactic; the patient who is suffering from it should be careful to avoid all 
causes of renewed inflammation ; he should keep the affected parts clean 
and cool, should not expose himself to cold or vicissitudes of temperature, 
and should avoid all over-fatigue and exposure of the parts to irritation or 
injury. Moreover, these should not be allowed to be pendulous. During 
the inflammatory stage antiphlogistic remedies may be had recourse to ; 
fomentations or cold lotions should be applied locally, with the object of 
preventing hypertrophy, and it may be of promoting absorption ; and the 
affected region should (if its form or position permit) be kept evenly and 
firmly bandaged. Hebra recommends that the bandage be of cotton, and 
dipped in water at the time of application. He further recommends that, 
previous to the use of bandages, scales and crusts be removed by cata- 
plasms, baths, or greasy application, and that afterwards mercurial oint- 
ment be rubbed in. 



XIX. MOLLUSCUM CONTAGIOSUM. 

Causation and description This is an affection occurring mainly 

among children, and characterized by the development of small globular 
or sub-globular outgrowths from the skin, usually varying from the size of 
a pea downwards, but occasionally attaining larger dimensions. They are 
sessile, though sometimes attached by constricted bases. They differ little 
if at all in color from the surrounding skin, but have a slight degree of 
translucency. They are unattended with pain or itching. Each tumor 
for the most part presents a distinct central depression, from which can 
often be expressed a little milky fluid or wax-like substance. On section 
it is found to consist of a lobulated gland-like body, the crypts of which are 
lined with columnar epithelium, and filled with rounded cells of large size. 
All these crypts communicate with a central duct, which for the most part 
is full of cells containing fatty matter. The growth appears in fact to be 
in some sense a kind of epithelioma. Molluscum has been supposed to be 
due to some abnormal development of the sebaceous glands ; but both 
Beale and Virchow regarded it rather as taking its origin in the hair- 
follicles. We believe, however, that we have seen molluscous tumors in 
the palm of the hand. 

Whatever the nature of the disease may be, we consider that it has 
been clearly proved to be contagious. It frequently occurs simultaneously 
among the children of a family, and under such circumstances even the 
adult members occasionally become affected. The parts on which the 
tumors chiefly appear are the face, head and neck, and trunk ; but they 
occur also on the limbs. 

Treatment — Local measures only are of use. If the tumors are attached 
by narrow bases they should be snipped off; if by broad bases, they should 



316 



DISEASES OF THE SKIN. 



be effectually cauterized with nitrate of silver, potassa fusa, acid nitrate of 
mercury, or the like, previous to which it may be well to lay them open 
with a scalpel. 



XX. PHTHIRIASIS. (Lousiness.) 

Causation and description Lice, the presence of which gives rise to 

the affection sometimes termed phthiriasis, are of common distribution as 
parasites throughout the animal kingdom. Three varieties affect man, 
namely the pediculus capitis, the pediculus restimenti, and the phthirkis 
(or pediculus) pubis. The first of these as a rule inhabits the head only ; 
the second lives in the underclothing and feeds on those parts of the body 
which are uncovered with hair ; the last infests the hair of the pubes and 
the armpits, and less frequently the eyebrows, eyelashes, whiskers, beard, 
and moustache. 

A. The pediculis capitis or head-louse is generally of a gray color like 
that of the scurf, and hence is very readily overlooked ; it has, however, a 
dark streak (alimentary canal) along the central line of its body, the pres- 
ence of which may aid in its detection. It lives among the hairs close to 
the scalp, feeding for the most part on the scurf and even upon the hairs, 
and running along the latter with considerable agility. The female, which 
is larger than the male, deposits her eggs or nits upon the hairs, attaching 
them thereto by a tough transparent sheath. These, which may be readily 
mistaken for particles of scurf, are fixed upon the hairs much as are the cocoons 
of some moths upon the stalks of grass, are furnished with a lid, and mea- 
sure about half a line in length. The female, according to Kuchenmeister, 
begins to lay eggs at the end of eighteen days, and lays about fifty. They 
are hatched in six days. 

Pediculi always cause more or less itching and consequently a tendency 
to scratch the head with the nails. This may be all. But in many cases 
the irritation which they produce leads to the development of eczema or 
impetigo, and the formation of thick scabs. As Mr. B. Squire has pointed 
out, impetigo in children limited to the back of the head is often of pedi- 
cular origin ; and impetigo affecting the nape of the neck in adults (espe- 
cially females) is also commonly attributable to lice. There is good reason 
to believe that the affection termed ' plica Polonica' is nothing more than a 
combination of filth, lice, and entanglement or felting of the hair. We may 
add that pediculi (then termed 1 p. tabescentiuni') are very apt to accumulate 
in the heads of patients suffering from long and wasting illnesses. But 
there is no sufficient reason for regarding them as distinct from the common 
head-lice. 

B. The pediculus vestimenti or body-louse is scarcely distinguishable 
from the last, excepting by its larger size, and its habits. It lives in the 
under-clothing, and attaches its eggs to the superficial projecting fibres. It 
is not always easy to detect its presence, for it is only occasionally dis- 
covered crawling upon the skin, or even upon the plane surface of the shirt 
or chemise. It almost always lies concealed in the folds or pleats; and it 
is in these situations also that its eggs are deposited. The eggs, moreover, 
though almost exactly resembling those of the head-louse, have generally 
so much the color of the garment to which they adhere that they are seen 
with considerable difficulty. 



SOABIES 



317 



Body-lice, like the last, often cause itching only ; but often after a time, 
the constant irritation of their presence leads to the development of an in- 
distinctly papular condition of the skin, and bleeding points and lines, the 
consequences of violent scratching. This state of skin closely corresponds 
with the ordinary descriptions of prurigo. And indeed there can be no 
doubt that the great majority of cases of so-called ' prurigo senilis'' are 
essentially cases of phthiriasis. The presence of body-lice not unfrequently 
also causes urticaria, lichen, and eczema. 

C. The pediculus pubis or crab-louse is very different in form from the 
other species of louse. It presents a much broader thorax and abdomen, 
and its chitinous claws are much more elongated and massive. It never 
affects any other parts than those which have already been named as its 
habitat; always nestling close to the skin, and biting deeply into it. It 
fixes its eggs, which resemble those of the head-louse, close to the points 
of emergence of the hairs. 

The pediculus pubis causes violent irritation, and frequently induces an 
impetiginous eruption and the formation of abundant scabs. 

Treatment It is usually not difficult to get rid of lice. The thorough 

use of soap and water, and thorough personal cleanliness, are of course 
essential, but alone are not generally sufficient. Many local applications 
will destroy them, but none probably is more efficacious than daily wash- 
ing with decoction of staphisagria seeds, or the inunction of the parts (as 
recommended by Mr. B. Squire) with oil of stavesacre diluted with olive 
oil, or the application of mercurial ointments, such as the ammonio-chlo- 
ride. The remedy must of course be continued until all nits (as well as 
lice) are removed or dead. It is often desirable, in order to promote cer- 
tainty and rapidity of cure, to hunt out and destroy the pediculi one by 
one, to pluck or cut out the nit-bearing hairs, and even to shave the head 
or other hairy parts. The applications which have been enumerated are 
useful even in the treatment of the pediculus vestimenti, but the chief 
treatment here must be directed to the clothes. Not only, however, must 
these be frequently changed and washed, but the bedclothes must be simi- 
larly treated, as must also the clothes of any one sharing the same bed. 



XXI. SCABIES. (Itch.) 

Causation and description. — Itch is a skin disease dependent on the pre- 
sence of the acarus scabiei, and marked by the development of a papular, 
vesicular, or pustular eruption, with intolerable itching, which is especially 
violent in the evening and at night. 

The acarus scabiei is an animal not unlike a cheese mite, both in gene- 
ral form and in color, and is visible to the naked eye as a minute white 
ovoid speck. Its body has a short oval form, is convex above, somewhat 
flattened below, studded with numerous spines and bristles, and furnished 
(in the adult state) with eight legs. In the female the four front legs end in 
stalked suckers, the four hind legs in bristles. In the male the hindermost 
pair of legs, as well as the four front legs, present suckers. The acarus 
just escaped from the egg has six legs, the hindermost, or fourth pair, 
only making their appearance after the first change of skin. The 
male is a little more than half the length and breadth of the female. 



318 



DISEASES OF THE SKIN. 



The egg, which is oval, measures about one-third the length of the adult 
female. 

The acari live for the most part in burrows (cuniculi) which they make 
for themselves in the substance of the epidermis, beneath its horny layer. 
According to Hebra, about a fortnight elapses from the time of hatching 
until the complete development of the animal. At the end of that time 
the impregnated female penetrates the corneous layer of the skin, and then 
slowly tunnels beneath it in a straight, zigzag, or curved line. In its on- 
ward progress it deposits eggs, sometimes as many as fifty, in a linear 
series ; and at the end of two or three weeks, or it may be six (Hebra), it 
dies at the further end of its burrow. This may then have attained the 
length of half an inch, or an inch, or even more than that. It is generally 
quite obvious, on careful examination, as an irregular line, studded with 
sub-cuticular black matter (feces; ; presenting, at its commencement, in 
consequence of the gradual desquamation of the skin, a groove w r ith retreat- 
ing sides — a kind of calamus scriptorius — and at its opposite extremity a 
minute papule, in which the white body of the animal can generally be 
pretty readily distinguished. The formation of the burrow and its full de- 
velopment may be unattended with visible signs of inflammation ; but not 
unfrequently papules, vesicles, or pustules rise up in its immediate neigh- 
borhood, the burrow then passing over them, or alongside of them, but 
very rarely forming any communication with them. Sometimes strings of 
vesicles, running perhaps together, mark its whole length. The eggs con- 
tained within the burrow hatch there and the young speedily migrate. 
The male acarus is difficult of detection, partly from its minuteness and 
comparative infrequency, and partly from the fact that it either simply 
imbeds itself in the skin without burrowing, or rambles over the general 
surface. 

The acari mostly burrow about the w r rists and hands, especially on the 
palmar aspect, and between the fingers, and in the corresponding situations 
in the lower extremities ; they also infest the nipples and organs of gene- 
ration, the flexures of the elbows and knees, the axillae and the buttocks. 
No part can be regarded as necessarily exempt from their ravages. The 
face and head, however, are rarely attacked. The presence of the acari 
causes intolerable itching, which increases at night time, and provokes 
violent scratching. It also gives rise to inflammatory eruptions — papules, 
vesicles, blebs, or pustules — which are to be looked for especially on those 
parts of the surface which the acari chiefly affect ; and occasionally it in- 
duces urticaria, eczema, or impetigo, which are not necessarily limited to 
the neighborhood of the burrows, and may become general. The papular 
and vesicular forms of eruption are the most common. The pustular va- 
riety shows itself for the most part in persons who are out of health or 
possess peculiarly susceptible skins. Sometimes the inflammation becomes 
excessive, and produces not only pustules but considerable inflammatory 
exudation and infiltration. This condition may often be observed in the 
penis and the nipples. The disease has naturally little or no tendency to 
spontaneous cure ; but can certainly be kept in abeyance by personal clean- 
liness. Under opposite conditions, however, it is apt to become greatly 
aggravated. Occasionally the tips of the fingers and toes, with the nails, 
get destroyed, partly by the direct operation of the acari, partly by the 
ulceration which they induce. A very severe form of the disease, common 
in Nonvay (and hence termed ' scabies Norvegicd 1 ), but not confined to 
that country, is characterized by the formation of thick tough crusts ex- 



SCABIES. 



319 



tending over the palmar surface of the hands and fingers, and the corre- 
sponding surface of the feet and toes, the parts beneath being excoriated 
or ulcerated. The crusts contain innumerable acari and ova, both living 
and dead. 

From the different degrees of severity which it presents, and from the 
very various eruptions to which it gives rise or with which it may be asso- 
ciated, itch is a disease which, on the one hand, is very apt to be over- 
looked when present, and, on the other hand, is very liable to be assumed 
as present when the patient is entirely free from it. The appearance of a 
papular, vesicular, or pustular itching eruption between the fingers and 
about the wrists, and in other situations which itch affects, is no doubt an 
important indication ; but similar eruptions, not due to the acarus, occur 
in these same localities. The transference of the disease to a bed-fellow 
or to those with whom the patient has similarly close relations, is also a 
point of great significance ; but it must not be forgotten that one member 
of a household may have itch for months and yet fail to infect any of the 
other members. The only real proof of its presence is the discovery of the 
acari, their eggs, or their burrows. The burrows are sometimes marvel- 
lously well seen, presenting all the characters which have been already 
described ; but they are often incipient, and very difficult of recognition. 
When they are distinct the discovery of the female acarus is easy. It -can 
generally be seen, even with the naked eye, at the further extremity of the 
burrow, or apparently a little beyond that point, as a very minute whitish 
papule. If the surface of this papule be torn with a pin, the acarus may 
readily be removed from its bed on the point of the instrument. In per- 
forming this operation it is well to avoid wounding any neighboring vesicle 
or pustule. Even in cases where, no obvious burrow exists, the acari may 
be occasionally detected in the neighborhood of some of the itching papules 
by the presence there of the minute whitish elevations which they cause. 
Sometimes, even when distinct burrows are present, there is some difficulty 
in detecting the acari at their extremities ; in such cases one of the bur- 
rows may be broken down, and its contents removed on the point of a pin 
or lancet, or, still better, a whole burrow may be cut out. By these means 
the ova may be readily obtained. A further plan is to remove the scabs, 
if there be any, to boil them in a solution of caustic soda until they become 
limpid, and after allowing the fluid to stand for a time in a conical glass, 
to examine the deposit with a microscope. Dead acari, including males, 
and six-legged grubs, and ova, can often be obtained by this process. 

Treatment — The essential object in the treatment of scabies is the destruc- 
tion of the acari and their ova. For this purpose it is necessary not only 
to apply an appropriate parasiticide, but to soften the skin and remove its 
superficial epidermis so as to expose the burrowing mites to its influence. 
The patient therefore should have daily hot baths, use soap abundantly, 
and rub the surface thoroughly with a flesh-brush or a rough towel. All 
scabs should be removed. Then sulphur ointment, either those of the 
Pharmacopoeia, or that of Helmerich, which contains carbonate of potash, 
should be rubbed well into the skin, especially into those parts which seem 
most affected, and should remain upon the skin until the next bath. Treat- 
ment of this kind will generally cure itch in the course of a few days or a 
week, but may not improbably induce eczema or some other form of super- 
ficial inflammation, which will need other remedies for its cure. No doubt 
less active measures will suffice to cure scabies, but the cure will probably 
then be long delayed. On the whole, however, when a person has itch it 



320 



DISEASES OF THE SKIN. 



is better for himself, in the long run, and better for those with whom he 
associates, that he should recognize his condition, retire for a few days 
from public life, and adopt the measures which will most speedily work a 
cure. Tincture of benzoin and balsam of Peru, far more agreeable appli- 
cations than sulphur, are said to be more efficacious than it in the cure of 
itch. They should be rubbed well into the atfected parts. The purifica- 
tion of the patient's clothes and bedclothes forms an essential part of the 
treatment. 



XXII. OTHER SKIN-AFFECTIONS CAUSED BY 
ANIMALCULES. 

Causation and description — Fleas, bugs, and gnats do not of course 
come under the category of parasitic animals. So many persons, however, 
suffer from their bites, and the effects of their bites are so often misinter- 
preted, that it seems desirable to make a remark or two in reference to 
them. A recent flea-bite always exhibits a punctiform subcutaneous ex- 
travasation of blood, surrounded by a comparatively broad rosy areola. 
The latter soon disappears ; the former may persist for several days. 
People, and especially children, of the lower classes are often thickly 
covered with such petechial spots in different stages of their progress; and 
their skin, when seen for the first time (especially if they be suffering from 
some febrile disturbance), is very apt to suggest the presence of the typhus 
eruption. The smallness, however, of the spots, their uniformly petechial 
character, and the probable detection in them on close inspection of the 
puncture made by the insect, will alone, for the most part, enable a careful 
observer to distinguish the eruption due to fleas from that of any of the 
specific fevers. In some persons flea-bites produce considerable irritation 
and the development of wheals or tubercles, associated sometimes with a 
large amount of subcutaneous effusion of serum. The effects are then not 
unlike those which commonly arise from the bites of gnats and bugs. In 
all these cases there is generally in the first instance violent itching, which 
is followed presently by the formation of a wheal or tubercle from the size 
of a split pea downwards, and very often by more or less considerable sub- 
cutaneous oedema. The latter pretty soon subsides ; but the wheal pro- 
bably continues for a week or fortnight, and is generally attended with 
itching during the whole of that time. In its progress (owing in some 
measure to scratching) punctiform extravasations of blood often take place 
into its central part, and these are sometimes succeeded by vesication, or 
the formation of a pustule. Sometimes the wheals gradually subside and 
disappear ; but in many cases their subsidence is attended with the sepa- 
ration of a squama, or the formation and detachment of an eschar, or, 
when there has been vesication or suppuration, the production of a scab. 
It need scarcely perhaps be said that gnats generally select exposed parts 
of the skin, fleas those regions which are protected by clothing, and that 
bugs are more indiscriminate in their attacks. There is no doubt that the 
bites of these insects, especially in children of delicate skin, produce erup- 
tions the source and nature of which are apt to be entirely overlooked. 
Many attacks of so-called ' strophulus,' ' lichen,' and ' impetigo,' ascribed 
to dentition, dyspepsia, and other causes, are really due to the operations 
of the above animals. Mosquito bites are almost identical with gnat bites 



TINEA TONSURANS. 



321 



in their effects ; they are generally, however, much more numerous and 
individually more venomous. 

The leptus autumnalis, or harvest-bug, which is of common occurrence 
in the autumn in grass and cornfields and among gooseberry bushes, is 
very apt to imbed itself in the skin, and to cause much irritation there. 
The effects pass off in about a week. The mite, which is just visible to 
the naked eye, is of a red color and presents six legs. It is probably the 
immature condition of an unrecognized eight-legged animal. 

The pulex penetrans {chigoe) is a native of South America and the 
"West Indies. It is so small as to be seen with difficulty, and is charac- 
terized by the possession of a proboscis as long as its body. Only the im- 
pregnated female attacks man. It penetrates the skin of the feet and 
toes, generally in the neighborhood of the nails, where its impregnated 
body quickly develops itself into a white vesicle the size of a pea. This 
enlargement is due to the rapid growth of the larva?, which, if the cyst be 
ruptured, escape into the surrounding tissues and cause in them severe in- 
flammation with suppuration. The recognized mode of treatment is to 
dilate with a needle the orifice by which the intruder entered, until it is 
large enough to allow of its extraction without rupture. 

On the Island of Bulama and its neighborhood, on the West Coast of 
Africa, a pimple ultimately attaining the dimensions of a boil, and then 
attended with much pain and surrounding inflammation, and even affection 
of the neighboring lymphatic glands, is attributable to the grub of some 
insect, which is deposited doubtless in the egg beneath the skin y and at- 
tains its full growth in that situation. The perfect insect is unknown. 

The acarus (demodex) foUiculorum resides in the sebaceous follicles,, 
for the most part in the duct or about the spot at which the sebaceous 
follicle opens into that of the hair. It is sluggish in its habits, and lies 
imbedded in the sebum with its head pointed inwards. The number of 
acari in a follicle vary from one upwards. As many as- thirteen have been 
discovered at one time (Kiichenmeister). They differ in size, and in some 
degree in form, with age. In the earlier period of their development they 
present six, and subsequently eight legs. They are most commonly found 
in the comedines of persons suffering from acne punctata, but do not cause 
this affection, or apparently aggravate it. In order to find them the ex- 
pressed sebum should be diluted with oil, and then submitted to micro- 
scopic examination. This parasite causes no distinctive symptoms in 
man ; but is said to produce serious and sometimes fatal consequences in 
the dog. 



XXIII. TINEA TONSURANS, (Porrigo scutulata. Ringworm.) 

Causation and description Ringworm depends upon the presence of a 

fungus, termed ' tricophyton tonsurans,'' which chiefly affects the roots and 
shafts of the hairs, but also invades the epidermis and the nails. Its my- 
celium consists of filamentous jointed branching tubes, which in the hair 
run in groups parallel with its long diameter, but in the epidermis and 
nails form an irregular interlacement. The spores are minute oval or 
rounded bodies, formed, in the first instance, in linear series at the extre- 
mities of the mycelial filaments - T but soon so abundantly developed that 
this relation is entirely lost. Spores form both in the epidermis and in 
21 



322 



DISEASES OF THE SKIN. 



the nails, but their chief seat is the shafts of the hairs within and a little 
external to the skin. The fungus spreads superficially, as do most fungi, 
in gradually enlarging circles, which, however, from various accidental 
circumstances, often expand irregularly, and often, when they are large, 
break up into irregular segments, and often, moreover, present fits of alter- 
nate quiescence and growth. 

When ringworm occurs on the non-hairy skin, it reveals itself first as a 
slightly raised roundish uniformly erythematous patch, a line or two in 
diameter. This slowly increases in size, becoming at the same time more 
distinctly circular; and when it attains perhaps half an inch in diameter 
the inflammation at the centre begins to subside, and the patch thus be- 
comes a ring. In its further progress the ring may enlarge to the size of 
half-a-crown, or a crown, and still extending (but then for the most part 
irregularly), may creep, for example, over the whole side of the face or 
front of the chest. The margin of the patch is always red and elevated, 
but varies in breadth, and often presents papules or vesicles ; and hence 
the affection has been called indifferently erythema circinatum, lichen cir- 
cinatus, and herpes circinatus. The central area, even if all inflammation 
appears to have subsided in it, still retains a yellowish or brownish dis- 
coloration, and a tendency to scale. Moreover, fresh spots of inflamma- 
tion are apt to appear here and there upon it. Occasionally, patches of 
ringworm present two or three concentric erythematous rings, separated 
by rings of fairly healthy integument. There is no doubt that this variety 
has often been termed erythema, lichen, or herpes iris. 

When the nails are attacked, which is rare, they become in the affected 
parts irregular, thick, softer than natural, and at the same time more or 
less opaque and of a yellowish tint. The fungus penetrates them generally 
from the root, and not unfrequently the adjoining surfaces of the fingers, 
and the hands, are at the same time involved. 

The most important, if not the most common seat of ringworm, is the 
head. Here the circular form of the affection and its erythematous or 
vesicular margin are seldom distinguishable. The patches, however, are 
generally well-circumscribed, and are indicated — partly by an abundant 
formation of adherent glistening scurf, which clings around the bases of 
the hairs, and is continuous with the lining of the hair-sheaths, and by its 
peculiar scaly character, has given to ringworm one of the names, porrigo 
scutulata, by which it was formerly known ; and partly by the condition 
of the hairs, which become swollen, dull and opaque, limp and lacerable, 
so that they break off either at the surface of the scalp, or a line or two 
above it. This breaking off of the hairs produces a marked resemblance 
to a stubble-field, and has suggested the common name of the disease, t. 
tonsurans or tondens. This stubbly character may be concealed, and the 
surface rendered apparently bald, by accumulation of scurf. On removal 
of this many of the broken hairs are removed with it. 

Ringworm sometimes in men attacks the beard, moustache, and whiskers, 
producing one of the varieties of sycosis. It there excites (as it does 
occasionally in the scalp) considerable inflammation, causing deep-seated 
-suppuration about the sebaceous glands and roots of the hair, and is very 
intractable. 

Ringworm is generally attended with more or less itching, especially if 
the head be the part affected. It is highly contagious, and is particularly 
liable to spread amongst children. Adults, however, especially those who 
are in attendance on affected children, often take it. But in them it is 



TINEA FAVOSA. 



323 



limited for the most part to the nails and fingers, and other non-hairy parts 
of the skin. Many suppose that it attacks mainly those who are in en- 
feebled health. But this is doubtful. When confined to the general 
surface it can, for the most part, be easily cured. In the head, however, 
or the beard, or nails, its eradication is extremely difficult and apt to be 
long delayed. Children may suffer from it for several years ; and we have 
known it to persist in the finger nails of an elderly lady for at least seven 
years, never during that time extending to other parts of her body. Tinea 
tonsurans affects the horse and some other of the lower animals. 

Treatment The treatment of tinea tonsurans is purely local, the main 

object being to destroy or remove the fungus which produces it. Many 
substances are recommended as parasiticides, the most important being 
the sulphurous acid of the Pharmacopoeia, and empyreumatic substances, 
such as unguentum picis liquidum (diluted or not), unguentum creasoti, 
oil of cade, and the like. In the treatment of ringworm of the head or 
beard, it is of great importance that the surface be kept close clipped or 
shaven, and by washing with carbolic soap and water free from scales or 
other kinds of exudation. Further, it is desirable that all affected hairs 
be removed from the morbid patches by daily diligent epilation. After 
each daily washing and epilation the specific medicament should be applied 
and kept applied : sulphurous acid by means of several folds of lint satu- 
rated with the solution and covered with oiled silk or paper; ointment by 
being rubbed in and then left in a thick coat on the surface. In the case 
of ringworm of the body, the same measures as to cleanliness and specific 
applications may be pursued; but here it is often advantageous to destroy 
the affected surface of the skin with some caustic, such as nitrate of silver, 
strong acetic acid, iodine paint, or blistering fluid. When the nails are 
involved, the surface should be removed in slices and sulphurous acid or 
creasote ointment freely and constantly applied. 

Ringworm of the head and beard is very apt to reappear weeks or even 
months after apparent cure. The reason of this is of course obvious. It 
is important therefore that the treatment should be prolonged far beyond 
the period of apparent cure, and that the hairs of affected areas should be 
from time to time carefully examined. Dr. Duckworth has recently 
pointed out that if a few drops of chloroform be dropped on suspected por- 
tions of the head, diseased hairs acquire an opaque yellowish-white color, 
the healthy hairs remaining unaffected. 



XXIV. TINEA FAVOSA. (Favus. Porrigo Favosa and Lupinosa.) 

Causation and description. — The cause of favus is the growth in the 
skin of the fungus known as the 4 achorion Schdnleinii.' This consists in 
a jointed mycelium, differing little from that of the tricophyton tonsurans, 
and like it invading the epidermis, nails, and hairs. It differs essentially, 
however, from the tricophyton in the seat and character of its fructification. 
The formation of sporules begins with the development of short rounded 
joints or sporules at the extremities of certain of the mycelial tubes, and a 
complex development of other sporules from them by budding. The first 
evidence of fructification to the naked eye consists in the appearance of 
minute disk-shaped sulphur-yellow spots beneath the horny layer of the 



324 



DISEASES OF THE SKIN. 



epidermis, or of minute yellow cups at the points of emergence of hairs. 
These gradually increase in size, until they form yellow cupped disks from 
^ to ^ inch in diameter, through the centres of which hairs not unfre- 
quently pass. On breaking these masses up they are found to be white 
within and brittle, and microscopically to consist of sporules seated in a 
finely granular matrix. 

The early stage of favus, which is commonly overlooked, and is most 
obvious when the disease attacks the smoother parts of the body, consists, 
like that of ringworm, in the appearance of small circles of erythema, 
which soon enlarge and become rings, and may then be studded with 
papules or vesicles. These rings of herpes or lichen carcinatus rarely grow 
larger than a sixpence or a shilling and are at first absolutely undistin- 
guishable from those of ringworm ; but soon there appear here and there 
at the edges or over the surface of the disks the characteristic yellow points 
of fructification ; and these rapidly attain their full dimensions. The 
mature favi, if discrete, maintain their characteristic form and appearance ; 
but where many of them are developed in close contiguity with one another 
they are apt to blend, and before long to form a prominent, irregular, 
mortary mass crossed superficially by an imperfect network of undermined 
epidermis, and presenting collectively an appearance not altogether unlike 
that of a rupial scab. Not unfrequently the progress of favus is attended 
with considerable inflammation, and even suppuration, the products of 
which blend with those of the vegetable growth. Under these circum- 
stances the neighboring lymphatic glands also become inflamed. As a 
rule, however, favus is attended with little local irritation, and little itch- 
ing. It is characterized generally by a peculiar mousy odor. 

Favus most frequently attacks the head, and leads to the falling out of 
the hair, and the growth in its place of thin, colorless, woolly hairs, and 
often causes subsequently total destruction of the hair-follicles, and per- 
manent baldness. The affected hairs, however, are not rendered brittle, 
as in tinea tonsurans, and therefore do not break off. Nails attacked with 
favus do not differ appreciably from those which are the seat of ringworm. 

Favus is of rare occurrence in England, but in Scotland appears to be 
somewhat common. It is limited almost entirely to persons of filthy habits, 
and generally begins in childhood. When treated in its early stage it is 
easily cured ; but when it has infected a large area it is exceedingly in- 
tractable, and will often (notwithstanding careful treatment) persist for 
many years. That this, like other parasitic diseases, is infectious, is be- 
yond doubt ; nevertheless, it is remarkable how rarely (compared with 
tinea tonsurans) it spreads among children, or from one member of a 
family to another. Favus is a common and fatal disease in mice. Cats 
also sometimes suffer from it. 

Treatment — The principles and details of the treatment of favus are as 
nearly as possible identical with those of the treatment of ringworm. In 
the first place all the favi should be removed by washing- poulticing, or 
the employment of oleaginous applications. Then the surface should be 
kept scrupulously clean, and treated by such parasiticide remedies as are 
useful in ringworm. Persistent epilation is of essential importance. In 
severe cases it is necessary to continue the treatment for many months, a 
year, or longer. Yet even when thus apparently cured, it not unfrequently 
breaks out again as soon as treatment is discontinued. 



TINEA VERSICOLOR — 



ALOPECIA AREATA. 



325 



XXV. TINEA VERSICOLOR, (Pityriasis Versicolor. Chloasma.) 

Causation and description This disease is caused by the growth among 

the epidermic cells of a fungus, termed the ' microsporon furfur.'' The 
mycelial tubes are about equal in thickness to those of the fungi which 
have been above described, but their texture is more delicate. They form 
an interlacement in the substance of the epidermis, but do not invade the 
hairs or nails. The spores are developed in microscopic clusters, some- 
what resembling bunches of grapes, scattered here and there among the 
mycelial tubes, and seem to originate within buds springing from the sides 
or ends of certain of the cells of the mycelium. 

Chloasma is characterized by the formation of light-brown or liver- 
colored spots, which are slightly elevated above the general surface of the 
skin, covered with a more or less abundant branny scurf, and attended 
with slight itching. The primary spots have a circular outline, and vary 
perhaps from the third or fourth of an inch in diameter downwards. In 
the first instance a few such spots appear here and there. These increase 
in size, and soon other similar spots arise in their vicinity. By degrees 
neighboring spots blend, and thus more or less extensive tracts of skin 
become pretty uniformly covered, thee dges still presenting a sinuous char- 
acter, and the neighborhood numerous outlying solitary and coalescing islets. 

Chloasma seems never to attack children, and very seldom persons of 
cleanly habits and among the better classes of society. It is a disease of 
adult life, and not unfrequently appears in those who are consumptive or 
otherwise out of health. It usually commences on the chest or between 
the shoulders ; and thence may spread, over the abdomen and back, to the 
shoulders, upper arms and even forearms, and to the buttocks and thighs. 
But it never affects uncovered parts. This circumstance, together with 
the fact of its occurring mainly to those who wash little and seldom change 
their linen, seems to indicate that the disease originates in fifth. Like 
other parasitic diseases it is contagious, but its contagiousness is not well 
marked. 

Treatment — In the treatment of chloasma perfect cleanliness is neces- 
sary. The affected parts should be daily washed with soap and water and 
well scrubbed with a flesh-brush or a rough towel ; after which, one of the 
parasiticide applications should be well rubbed in. Under these measures 
the disease soon becomes apparently cured. Its complete cure, however, 
demands persistence in treatment long after all visible traces of the dis- 
ease have disappeared. 



XXVI. ALOPECIA AREATA. 

(A. circumscripta. Porrigo or Tinea Decalvans.) 

Causation and description. — This is an affection mainly of the hairy 
scalp, but occasionally also involves the eyebrows and eyelashes, the beard 
and whiskers, the hair of the armpits and pubes, and, it may be, even the 
general surface of the skin, and is characterized by the temporary or per- 
manent loss of hair in more or less distinctly circumscribed areae. 

A well-developed patch of alopecia areata of the scalp is usually quite 



326 



DISEASES OE THE SKIN. 



unmistakable. It is a well-defined bald surface of circular or sinuous out- 
line, for the most part clean, smooth, and shining, and free from conges- 
tion or scurfiness. The skin indeed appears to be, if anything, thinner 
than in health, and the orifices whence the hairs should emerge are atro- 
phied and indistinct. The patch may be perfectly bald in its whole ex- 
tent, or may present here and there groups of such downy hairs as consti- 
tute the lanugo ; but not unfrequently a few long hairs still stud its surface 
at distant intervals ; and often in the neighborhood of these and of the 
margin may be seen on close inspection short club-shaped hairs, varying 
from about a line to j or | inch in length. These are most obvious in 
dark-haired persons, from the fact that each clubbed free extremity still 
presents the natural dark color ; but the portion of shaft between it and 
the scalp becomes more and more attenuated and more and more devoid 
of color as it approaches the latter. They can be pulled out more readily 
than healthy hairs, but still are generally attached with some degree of 
firmness. Their presence may be taken as indicative of the extension of 
the disease. When the alopecia has become arrested, downy hairs begin 
to show themselves over the bald area ; and these may gradually assume 
all the characters of the surrounding healthy hairs, or become coarse, and 
white or otherwise modified in color, or remain weak and scanty. Some- 
times new hairs grow up in the centre, while the disease is still spreading 
circu mferentially. 

Alopecia areata is for the most part of chronic progress, lasting gene- 
rally for months, often for years, or even for life. In some cases the patient 
presents only one or two circular spots, which enlarge up to a certain point 
and then undergo resolution. In some cases the disease continues to ex- 
tend indefinitely, partly by the enlargement of old patches, partly by the 
development of new ones, until the greater part of the scalp or even the 
whole scalp is involved, and until it may be the eyelashes and eyebrows, 
one after the other, and finally all other collections of hair disappear. 
Occasionally the progress of the disease is acute, the hair falling out 
rapidly and generally, though still perhaps more or less patchily. The 
final issue of the disease is uncertain. In the great majority of cases 
recovery takes place after a longer or shorter time ; but it is important to 
note that there is often a tendency for the disease to recur at irregular inter- 
vals, and not necessarily in the part originally affected. In no inconsider- 
able number of cases, and especially in those in which extensive tracts of 
surface have suffered, complete restoration of the hair never occurs; and 
in a few, absolute and permanent general alopecia ensues. 

The clubbed hairs above referred to present certain peculiarities of 
microscopic structure. The clubbed end is usually broken into a brush, 
and frequently presents in its interior an irregular group of largish cells, 
which are evidently the cells of the axis of the hair, at that part, modi- 
fied in character. From this point downwards the hair becomes more 
and more attenuated, until it ends in a very slightly dilated point, which 
represents the imperfect root. Occasionally, a little below the clubbed 
extremity, the dwindling shaft is interrupted by a small knot, within which 
such a group of cells exists as is usually found in the clubbed end itself. 
Looking to the fact of the occurrence in the originally healthy hair, at a 
point which seems to separate the normal from the attenuated portion, of 
a spot in which there has been some sudden modification of nutrition and 
growth which renders the hair at this part brittle and peculiar in struc- 
ture ; and to the fact that the portion of the shaft subsequently formed 



PRURIGO. 



327 



becomes, in consequence of the gradual wasting of the hair-root, more and 
more attenuated, until it falls out bodily ; it would seem pretty certain 
that the diseased process, as it affects the hairs, depends on the gradual 
spreading from some central point or points of a wave of inflammatory or 
other influence which, as it passes over each hair-papilla momentarily 
excites it as it were to unhealthy over-production and then leaves it enfee- 
bled and perishing. This disease is asserted by Bazin and many others 
to be parasitic, and due to the presence of the microsporon Audouini. 1 
There can be little doubt, however, that this view is erroneous. It is 
believed also by many to be contagious ; but, this, again, is doubtless an 
error. It is certain, however, that it is apt, like psoriasis, to break out 
periodically in the same individual, and like that also to affect several 
members of the same family, and to be transmissible from parent to child. 
The disease is more common in children than adults, and in females than 
males. We have seen it in a child ten months old, and it is often met 
with, still progressing in persons between forty and fifty. Its presence is 
neither preceded nor accompanied by any general signs of ill-health, 
nor is its progress usually attended with any subjective local symptoms. 
Occasionally its commencement and spread are marked by more or less 
intense tingling or itching, so that the experienced patient not only knows, 
before the hair falls out, when a new patch of disease is commencing, but 
knows also when an old patch is spreading. 

Treatment. — The treatment of alopecia areata is very unsatisfactory. 
Many patients get well who are never subjected to any, and many go on 
progressively from bad to worse in spite of the most sedulous care. There 
are no obvious indications for constitutional treatment, but tonics and 
arsenic are often employed empirically. For local medication it is gene- 
rally thought best to use stimulants, and especially to blister the affected 
regions periodically with the acetum cantharidis or iodine paint. We do 
not believe that shaving the head is of any use, excepting for the purpose 
of facilitating the application of local remedies. It may be added that 
those who believe in the parasitic nature of the disease would naturally 
recommend the use of creasote, sulphurous acid, or other parasiticides. 



XXVII. PRURIGO. 

Description This name is given to a condition of the skin, attended 

with more or less violent itching, and usually marked by coarseness of tex- 
ture, and the presence of scratches produced by the action of the finger 
nails. It is uncertain whether there is any specific affection to which the 
name is applicable. Willan obviously included under this term mere pru- 
ritus, or itching from various causes, and especially that due to the pres- 
ence of body-lice. But he also included a papular affection which he 
regarded as quite distinct from other varieties of papular diseases. Hebra 
also describes a similar affection, which he considers to be sui generis, and 
to which he limits the use of the name. 

1 Recently M. Melassez claims to have rediscovered the specific fungus of this 
disease. He has seen spores of indeterminate character, and in very small num- 
bers, in the horny layer of the epidermis — none in the rete mucosum, none in the 
hairs. They are doubtless accidental ; at all events there is absolutely no ground 
for regarding them as the cause of the disease. — Archiv. de Pliysioloyie, 1874. 



328 



DISEASES OF THE SKIN. 



According to the latter authority, prurigo is a disease of remarkable in- 
tractableness, if not incurable, consisting in the development of flat papules, 
not differing in color from the skin, scarcely appreciable by the eye, but 
readily detectible by the touch, and leading to a general coarseness of tex- 
ture and more or less pigmental deposit. It may occur upon nearly all 
parts of the body, though rarely attacking all in the same individual ; and 
it especially affects in an increasing ratio the front and back of the trunk, 
and the extensor aspects of the upper arms and thighs, forearms and legs. 
The papules are apt to be irritated into inflammation or torn by scratching, 
and the eruption to be complicated, after a time, with eczema, impetigo, 
urticaria, and the like. Notwithstanding Hebra's authority, it may still, 
we think, be a question whether prurigo does not represent a heterogeneous 
group of ill-developed or ill-defined affections, attended with the common 
symptom of intense itching, and in which a coarse subpapular condition of 
skin is present, in consequence partly of some abnormal nutritive condition 
of the skin, partly of the influence of constant scratching and other varie- 
ties of irritation. According to this view, prurigo maybe a legacy left by 
eczema, impetigo, or erythema; or it may be present in persons liable to 
these affections during the periods when they seem to be free from them ; 
or it may be referable to phthiriasis or scabies, to jaundice or urasmia, to 
want of cleanliness, to the irritation produced in delicate skins by the too 
abundant and too frequent use of soap, or to excessive friction, either by 
the towel or by the clothes. 

Treatment For the treatment of prurigo, Hebra especially recommends 

sulphur, in the form of ointment, baths, or fumigation, tar in its various 
preparations, creasote, and frequent bathing. Besides these remedies lo- 
tions may be employed containing opium, prussic acid, acetate of lead, ace- 
tate of ammonia, or vinegar, or else black-wash, or mercurial or plumbic 
ointments. The constitutional treatment must depend on the patient's 
general symptoms or state of health, or on the nature of the ailment to 
which the pruritis is referable. AVhen the itching is due to parasitic affec- 
tions, parasiticide applications must be employed. 



XXVIII. CONCLUDING REMARKS. 

Besides the various affections of the skin which have just been passed 
in review, there are many others, of more or less interest, which could not 
be omitted from a work devoted to skin diseases, yet scarcely call for con- 
sideration in a manual of medicine. They are either of no practical 
importance, or they are extremely rare, or they fall entirely within the 
domain of the surgeon, or they are mere symptoms of more important 
disorders, and consequently are considered, so far as is necessary, elsewhere 
in this volume. We allude more particularly to such hypertrophic affec- 
tions as horns, corns, warts, noevi, fibromatous and fatty tumors, epitheli- 
oma, and other varieties of malignant disease which affect the skin prim- 
arily or secondarily, and form either circumscribed tumors or infiltrating 
growths ; to various atrophic conditions of the skin, hair, and nails, 
inclusive of the conditions to which Dr. Wilks has given the name of 
linear atrophy ; to increase or diminution of pigment (ephelis, lentigo, 
vitiligo, albinism) ; to the eruptions characteristic of many specific febrile 
disorders; and to such rare or ill-understood affections as fra?nbcesia, pel- 
lagra, and acrodynia. 



INTRODUCTORY REMARKS. 



329 



CHAPTEE III. 

DISEASES OF THE RESPIRATORY ORGANS. 

I. INTRODUCTORY REMARKS. 

A. Anatomical Relations. 

I. The organs of respiration comprise the larynx, trachea, bronchial 
tubes, lungs, and pleurae. 

Larynx and trachea. — The larynx is situated in the upper and fore part 
of the neck, extending from the hyoid bone above to the lower border of 
the cricoid cartilage below. The trachea commences at the lower border 
of the larynx, on a level with the upper orifice of the oesophagus and the 
fifth cervical vertebra, and runs downwards in the mesial line to the level 
of the third dorsal vertebra, where it divides into the two bronchi. The 
upper half of it is situated in the neck, the lower half in the chest, behind 
the sternum. Behind, it lies in contact in its whole length with the 
oesophagus. In front, it is embraced above, as low down as the fourth, 
fifth, or sixth ring, by the thyroid body, and below, just above its bifurca- 
tion, is crossed by the transverse arch of the aorta. The roots of the lungs 
are situated in the posterior mediastinum, on a level of the bodies of the 
fourth and fifth dorsal vertebrae ; the right bronchus, which is nearly hori- 
zontal, being on the level of the fourth vertebra behind and second costal 
cartilage in front ; the left, which passes down obliquely, reaching as low 
down as the fifth vertebra behind, and a little below the second costal 
cartilage in front. The latter passes under the aortic arch and is therefore 
in contact, above with the transverse arch, behind with the descending 
portion. 

Lungs — The apex of each lung rises above the first rib into the root of 
the neck ; and the posterior obtuse margin occupies the groove between 
the ribs and vertebrae as low down as the eleventh rib. The base of the 
lung varies in position with the varying position of the diaphragm. The 
vault of the diaphragm rises during expiration on the right side to the level 
of the fifth rib at the sternum, on the left to the level of the sixth, and of 
course therefore the liver on the right side and the stomach on the left 
attain these respective elevations. The outer margin of the base, however, 
owing to the upward convexity of the diaphragm, reaches to a lower level, 
and during medium distension of the lungs with air may be traced in nearly 
a direct line from the junction of the sixth costal cartilage with the sternum 
outwards and downwards to the head of the eleventh rib. During deep 
inspiration the edge may descend considerably between these extreme 
points. The anterior margin, like the lower one, varies in its position 
during the respiratory acts. When the lungs are moderately full their 
anterior borders are separated above by a triangular interval, the base of 
which corresponds to the sternal notch, the apex to the lower edge of the 
manubrim. From this point downwards to the interval between the fourth 



330 



DISEASES OF THE RESPIRATORY ORGANS. 



ribs, they continue parallel and nearly in contact. They then separate 
again, the edge of the right lung still passing vertically downwards, while 
that of the left retreats, forming a notch of which the apex corresponds to 
the junction of the fifth costal cartilage and rib, or to a corresponding 
point in the fifth interspace, and within which the heart becomes super- 
ficial. After a deep inspiration the anterior edges of the lungs are usually 
in contact from above down to the commencement of the cardiac notch ; 
after a deep expiration there may be an interval of an inch or two between 
them. The extreme apex of the lower lobe of either side is situated be- 
hind, and in the adult about three inches below the summit of the lung. 

Pleurce The cavities contained by the parietal pleurae correspond 

pretty accurately to the forms of the lungs ; they are, however, only fully 
occupied by the lungs when these are largely inflated- During ordinary 
respiration there is a portion of each pleural cavity beyond the lower 
margin of the lung, and another beyond the anterior margin, in which op- 
posed portions of the parietal pleura are in contact with one another. It 
must be added to this statement that the pleurae do not line the thoracic 
parietes quite down to the attachment of the diaphragm in front ; and 
that while the anterior margin of the right pleura extends to the mesial 
line of the sternum from the level of the second rib downwards, that of the 
left retreats somewhat at about the point at which the notch in the left lung 
commences. 

2. Regions of chest. — It is usual and convenient for clinical purposes to 
map out the chest into regions. The names of those which are generally 
recognized sufficiently indicate their respective positions. They are as fol- 
lows. — In front: the supra-sternal, situated immediately above the sternal 
notch; the upper- sternal, corresponding to the upper half, the lower ster- 
nal to the lower half, of the sternum ; the supra-clavicular, placed just 
above the inner half of the clavicle ; the clavicular, corresponding to the 
inner half of the same bone ; the infra-clavicular, extending from the 
clavicle downwards to about the level of the third rib; the mammary, of 
which the nipple may be taken as the centre, extending from about the 
third to the sixth rib; and the infra-mammary, comprising the remainder 
of the front of the chest; — at the side: the axillary, bounded by the sum- 
mit of the axilla above, in front and behind by the axillary folds, and ex- 
tending half-way down the thorax, and the infra-axillary, occupying the 
lower half of the lateral aspect of the chest ; — at the back : the upper scap- 
ular, situated above the spine of the scapula ; the lower scapula, corres- 
ponding to the infra-spinatus fossa; the inter-scapular, lying between the 
vertebral border of the scapula and the spinous processes of the vertebrae ; 
and, lastly, the infra-scapular, including all that part of the back of the 
chest situated below the lower angle of the scapula. We have not assigned 
exact limits to all of these regions, partly because different writers assign 
different limits to them, partly because, convenient though they are for 
ordinary purposes, it seems to us preferable, when there is need of exacti- 
tude, to define the position and limits of areae by reference to the ribs and 
other fixed landmarks, and by measurement. 

B. Pathology of Voice, Respiration, Cough, and Expectoration. 

In the investigation of diseases, and more especially those of the respi- 
ratory organs, much information may often be obtained by attention to any 
peculiarities which the voice or respiratory acts may present, to the pres- 



PATHOLOGY OF VOICE. 



331 



ence or absence of cough and to the quality of the cough, and to the char- 
acter ot the expectoration. 

1. Voice. — The voice may be feeble, tremulous, or absent, its quality 
or its pitch may be changed, and its register or compass may be contracted 
or modified. 

Mere feebleness of voice is so commonly associated with the presence of 
diseases, whether in the lungs or elsewhere, which cause enfeeblement of 
the muscular system generally, that it attracts comparatively little notice. 
It depends essentially on feebleness or imperfection of the expiratory act, 
however these conditions may be brought about. Hence we meet with it 
whenever there is much dyspnoea present, especially if at the same time 
the respirations be hurried and shallow ; and it is a notable characteristic 
of all cases in which, whether from disease of the spinal cord high up, or 
from any other cause, the diaphragm or the intercostal muscles or the 
muscles of expiration are paralyzed or weakened. Tremulous or bleating 
voice arises from want of accurate control over the expiratory muscles or 
over those of the larynx itself. It is met with chiefly in old age and in 
persons who are hysterical or nervous. 

Absence of voice, that is to say, total inability to produce laryngeal in- 
tonation, and the capability of evolving only that wheezy sound which 
forms the basis of all whispered vowels, indicates that the patient is unable 
to bring the vocal cords into apposition, and that the rima glottidis remains 
during his attempts at phonation in that patent condition which it affects 
during ordinary respiration. This condition is due to a paralytic state of 
the adductors of the vocal cords, which may be either of functional or of 
organic origin. 

The pitch of the voice depends on the action of the larynx alone. There 
are two widely different diseases in which the voice very frequently be- 
comes markedly high-pitched or squeaky ; these are Asiatic cholera and lep- 
rosy. It becomes high-pitched also in those who are under the influence of 
laughing-gas. Trousseau points out that when there is lesion of the supe- 
rior laryngeal nerves alone, there is, owing to the consequent paralysis of 
the crico-thyroid muscles, inability to utter the higher notes, and the voice 
consequently becomes deep-toned; and further that in some forms of laryn- 
geal inflammation, attended with hoarseness, the voice is low-toned on 
first rising, and becomes higher as the day advances. It is obvious that in 
the last two cases the compass of the voice also must be contracted. 

Pathological changes in the quality of the voice are largely dependent on 
conditions external to the larynx. It is thus that it gets altered when the 
faucial passage is narrow T ed by the presence of enlarged tonsils, when the 
soft palate is stiff and sore from inflammation, or paralyzed after diphtheria, 
or when there is cleft palate. Hoarseness or roughness of voice — in other 
words, loss or impairment of the musical quality of the voice — may depend 
upon any circumstance which interferes with the regular vibration of one 
or both of the vocal cords. Thus it may arise from inflammatory or other 
thickening of the cords, from ulceration, from the presence of warty or 
other growths, or from the adhesion of mucus or other matters to their 
surface ; and it not unfrequently arises simply from the fact that while 
one cord acts perfectly, the other cord is paralyzed. Hoarseness passes on 
the one hand into the normal intonation of the voice, on the other into 
absolute aphonia. 

2. Respiration — Ordinary quiet breathing is effected without appreci- 
able effort, and with scarcely audible sound, at the rate, in the adult, of 



332 



DISEASES OF THE RESPIRATORY ORGANS. 



from sixteen to twenty respirations in the minute — their number having 
to the beats of the pulse a ratio of about one to four or five, and the act of 
inspiration being probably somewhat longer than that of expiration. The 
respiratory acts are liable in health, and still more in disease, to many 
deviations from the above rule ; they may be modified in frequency, depth, 
and strength, and may be attended with more or less noise, discomfort, and 
effort. 

The frequency of respiration is diminished in syncope and collapse and 
various affections implicating the nervous centres, and occasionally also in 
cases of dyspnoea dependent on the presence of some mechanical obstacle 
to the entrance and escape of air. It is generally increased in inflamma- 
tory and febrile disorders, in affections of the lungs, pleurae, and heart, and, 
above all, in some forms of hysteria, in which indeed the acts have been 
known to exceed one hundred in the minute. The depth of the respiratory 
acts is usually in inverse proportion to their frequency. Hence when they 
are rapid, they are also, as a rule, shallow and inefficient ; when abnormally 
slow they are deep and labored. Under these latter circumstances espe- 
cially, the relative duration of inspiration and expiration is frequently 
considerably altered; in some cases, as in certain forms of gastro-intestinal 
disturbance and in some varieties of cardiac affections, the inspirations 
are prolonged and sighing; in others, and more especially in cases of 
emphysema, asthma, and mechanical obstruction of the larynx or trachea, 
the duration of expiration becomes relatively very largely increased. The 
respiratory rhythm is affected in another way in a variety of breathing to 
which Dr. Stokes has called special attention, which only occurs in a 
marked form when death is impending, and chiefly, he thinks, in cases of 
enfeebled heart. It consists in the occurrence of a series of inspirations, 
increasing to a maximum, and then declining in force and length until a 
state of apparent apnoea is established. 

The term dyspnoea is employed of all cases in which respiration is un- 
usually rapid, and equally of all those in which it is unusually slow, or 
even of normal rate, but attended with marked exertion. The special 
muscular efforts which accompany and indicate dyspncea are in some cases 
apparently limited to the dilatation of the nares during each inspiration ; 
in some to this act in conjunction with rhythmical opening of the mouth ; 
in other cases the muscles of the neck also act more or less powerfully; 
and between these conditions and the phenomena of the asthmatic parox- 
ysm, in which breathing is effected with the most agonizing efforts, and 
every ordinary and extraordinary muscle of respiration is called into 
powerful action, there are all gradations. The abnormal sounds which 
attend dyspnoea are sometimes a sniffing sound produced in the nares, some- 
times a sucking or sipping sound manufactured with the lips, sometimes a 
panting sound effected in the throat. 

Further, whenever the rima glottidis is narrowed, and incapable of en- 
larging to permit the free passage of the breath, or the trachea is dimin- 
ished in calibre, as it may be from the presence of a diphtheritic membrane, 
or the pressure of an aneurismal tumor, both inspiration and expiration 
acquire what is called a 4 stridulous' character ; they become remarkably 
harsh and rough, presenting in some cases almost a metallic ring. These 
peculiarities are always greatly increased when respiration is hurried, or 
during the inspiration which precedes a cough. Closely related acoustically 
to stridor is wheezing or whistling, which is a common attendant on old 
bronchitis, and always accompanies the asthmatic paroxysm. 



PATHOLOGY OF COUGH. 



333 



3. Cough is a modification of breathing, which is characterized by a 
deep-drawn inspiration, followed by closure of the glottis and a series of 
short but violent expiratory acts. It is generally excited by some irritation 
or abnormal accumulation, either at the glottis, in the trachea, or in the 
larger bronchial tubes; or it is a simple nervous affection. The act of 
coughing is generally preceded by tickling or some other uncomfortable 
sensation referable either to the larynx or to some part of the trachea. 
The cough may be unattended with expectoration or dry, either because 
there is nothing to be expectorated, or because the offending matter cannot 
be dislodged ; or it may be accompanied by more or less abundant dis- 
charge of mucus or other matters. In the first case the cough may be that 
of the early or dry stage of inflammation, or of hooping-cough, or it may 
be a nervous disorder. In the second case — that in which the cough is 
ineffectual — there is probably some mechanical obstacle in the larynx or 
trachea to the discharge of peccant matter, or clogging of the bronchial 
tubes with tenacious or even solid material, or limitation of the mucus to 
some of the smaller tubes. The third case does not call for special remark. 

All coughs are from their very nature spasmodic ; but some, from the 
entire want of control which patients have over them, and from peculiari- 
ties which they present, are especially deserving of that epithet. The 
most remarkable of these are the paroxysmal coughs which characterize 
pertussis, obstruction of the trachea, and spasmodic croup. In pertussis a 
deep inspiration is followed by a rapid succession of spasmodic expiratory 
efforts, continued until further expiration is mechanically impossible; then 
follows a long inspiration, effected through the spasmodically closed glottis, 
and yielding the characteristic whoop. In spasmodic croup there is a 
series of coughs, the expirations being remarkably harsh and noisy, the 
inspirations attended with a whistling sound. In tracheal obstruction, the 
inspirations are prolonged, stridulous, and wheezing, the expirations also 
wheezy and often unattended with marked laryngeal noise, and these are 
repeated in rapid succession until the patient appears on the eve of suffo- 
cation, when probably he is relieved by the discharge of a little mucus. 

The noises which attend the acts of coughing have already been partly 
considered. They may be divided into those of the inspiratory act and 
those of expiration. As regards the former, if there be spasmodic closure 
of the glottis, there is either a whoop, as in pertussis, or a whistle, as in 
spasmodic croup; but if the laryngeal orifice be obstructed by the presence 
of a false membrane upon it, or if there be an impediment in the trachea, 
the sound of inspiration becomes wheezy or harsh. In the majority of cases 
the sound of inspiration is merely that of a deep-drawn sigh. The sounds 
which attend the expiratory element of the cough are due to the condition 
of the laryngeal orifice and the force with which the expiratory blast bursts 
through it. Thus, if there be no impediment to the full inflation of the 
lungs, and the vocal cords be in a normal condition, the expiratory acts 
will necessarily (if forcible) be more or less noisy and at the same time 
musical. But the character of the sound will of course be modified accord- 
ing to the degree of tension of the cords, and in some measure in accord- 
ance with the degree in which they may have become thickened or have 
lost elasticity in consequence of inflammatory or other change. Many of 
the most noisy coughs are those which occur in hysterical or nervous 
patients, in whom the vocal cords are healthy in structure, and in those 
persons in whom they are affected with only slight catarrh. If, on the 
other hand, the vocal cords be prevented from vibrating freely, as may 



334 



DISEASES OF THE RESPIRATORY ORGANS. 



happen when the soft parts above the rima are greatly swollen, or the cords 
themselves and other parts of the larynx are invested with diphtheritic 
membrane, or laryngeal or tracheal obstruction renders the expiratory blast 
feeble and insufficient, the cough loses its musical or sonorous character, 
and becomes wheezy and voiceless. 

4. Expectoration The expectoration is often a valuable aid to diag- 
nosis. Many persons, especially those beyond middle age, spit on rising 
from bed in the morning a small quantity of viscid or tenacious mucus, 
studded with black particles. This black matter, which is supposed to be 
of extraneous origin, is nevertheless contained in cells. Such expectora- 
tion indicates the presence of a little bronchorrhcea, but is hardly to be 
regarded as a sign of any actual disease. In inflammation of the respira- 
tory passages, the discharge of mucus becomes augmented, sometimes 
enormously. This at first is a watery, slightly viscid, colorless fluid, of 
saline taste and reaction, containing microscopically shed epithelial cells 
and mucous and granular corpuscles. Later on, its viscidity increases 
(sometimes it is very viscid from the beginning), it becomes difficult to 
void, and coalesces after expectoration into a coherent mass, which adheres 
to the vessel into which it is discharged. Such expectoration is sometimes 
colorless, sometimes greenish or yellowish, and occasionally streaked with 
blood. At a still later stage, the sputa become opaque and yellow or 
green, less viscid, and acquire either the physical characters of pus or cha- 
racters between those of pus and mucus. This purulent conversion may 
be general or partial, and in the latter case the sputa not unfrequently pre- 
sent the so-called i nummulated' character, due to the fact of thick opaque 
pellets floating in transparent watery mucus. All these varieties of expec- 
toration may arise in the successive stages of acute or chronic bronchitis 
— the presence of pure mucus alone indicating for the most part acuteness 
of inflammation ; that of pus, the supervention of a chronic condition, or 
possibly the approach of convalescence. The nummulated character 
implies that, while the bronchial tubes are partly secreting mucus, they 
are partly secreting pus, or pus is gaining an entrance into them from 
other sources. Nummulated expectoration is frequently met with in cases 
of dilated tubes, of pulmonary cavities, and of empyematic or other ab- 
scesses which communicate with the lung and discharge through it. But 
it is also met with in simple chronic bronchitis. In many cases, when 
abscesses open into the lungs, the expectoration consists of almost pure 
pus. The expectoration of ordinary acute pneumonia is characterized by 
extreme viscidity with more or less transparency, and by the fact that it 
is uniformly tinged with blood. Its color presents numerous gradations 
between yellow or reddish-brown (rusty) and a bright vermilion. As the 
disease passes into convalescence, the expectoration loses its peculiar color 
and its viscidity and gets muco-purulent, like that of bronchitis. In cer- 
tain cases it becomes either distinctly purulent, or, while still incorporated 
with blood, watery. The latter form of expectoration is sometimes likened 
to plum-juice. 

Blood in streaks occurs in bronchitis, blood uniformly diffused in pneu- 
monia ; but very often unmixed blood is poured into the bronchial tubes, 
and is discharged thence, either still unmixed or blended only with a 
small quantity of mucus. The sources of such pulmonary hemorrhages 
are the bursting of aneurisms into the air-passages or lung-tissue ; the lay- 
ing open of branches of the pulmonary artery or vein during the progress 
of tubercle, carcinoma or other destructive morbid processes ; intense 



INVESTIGATION BY SIGHT AND TOUCH. 



335 



hyperemia of bronchial tubes or of the walls of pulmonary cavities ; and 
pulmonary apoplexy. In the last group of cases the hemorrhage is gene- 
rally scanty ; in the others it is often extremely profuse. Copious and 
sudden haemoptysis is generally characterized by the arterial character of 
the expectorated blood, and by its more or less frothy condition ; but when 
the hemorrhage is small in amount, and expectorated at intervals, it is 
often in the form of dark brownish or blackish-red pellets. 

Casts of the air-passages are not unfrequently expectorated. In diph- 
theria, membranous casts of various parts of the larynx, trachea, or larger 
bronchial tubes are often thus discharged. More rarely, branching casts of 
systems of the smaller bronchial tubes are spat up. These are sometimes 
mere coagulated blood, sometimes simple pneumonic exudation concreted 
in the smaller bronchial tubes, sometimes casts of laminated texture appa- 
rently identical with diphtheritic membrane. 

Among the foreign bodies which are occasionally expectorated must be 
mentioned hydatids, either from the lung itself or from the liver, and 
earthy concretions — the remnants of dried-up tubercular matter in the 
lungs or bronchial glands. No doubt tubercular, carcinomatous, and other 
such matters are occasionally brought up, but they can very rarely be re- 
cognized as such. The progress, however, of destructive processes in the 
lungs may often be detected or verified by the discovery on microscopic 
examination of fragments of lung-tissue. A convenient way of finding 
these is to boil a small quantity of sputum with a strong solution of caustic 
soda until they form a thin watery fluid, to place this in a conical glass 
for the purpose of subsidence, and then to examine the sediment micro- 
scopically. The matters to be especially looked for are the curved frag- 
ments of elastic tissue which bound the orifices of the smaller bronchial 
tubes, air-passages, and air-cells. 

Purulent expectoration often has a faint, sickly, or sweetish odor. The 
only smell, however, of clinical importance is that which is commonly 
attributed to the presence of gangrene. This is horribly fetid, difficult to 
describe, but when once smelt impossible to forget. It may be readily 
detected in the sputum itself; but it is evolved most intensely with the 
patient's breath during the act of coughing. The sputa which yield this 
odor are generally distinctly purulent, occasionally nummulated, and have 
usually a more or less discolored or dirty-looking aspect. They may be 
intermixed with blood in a more or less altered condition. [A fetor which 
is scarcely distinguishable from that of gangrene is, however, also occa- 
sionally perceived in cases of bronchiectasis, especially during the act of 
coughing.] 

C. Investigation by Sight and Touch. 

The information which may be acquired through the eye by inspection, 
and through the hand by palpation, as to the condition of those functions 
of the respiratory system which lie within the scope of such methods of 
investigation, is obviously very considerable. We will speak of them in rela- 
tion : first, to the larynx and trachea ; second, to the intrathoracic organs. 

1. Larynx and. trachea. Laryngoscope The apex of the epiglottis 

may sometimes be seen, and its condition ascertained, by merely looking 
into the throat when the mouth is widely opened and the tongue depressed. 
Its condition and also that of the parts bounding the upper orifice of the 
larynx may sometimes, especially in children, be roughly yet sufficiently 
determined by means of the tip of the forefinger passed back through the 



336 



DISEASES OF THE RESPIRATORY ORGANS. 



mouth into the fauces. The invention of the laryngoscope, however, and 
the perfection to which its use has been brought, make it now possible for 
us to determine the condition of the larynx with the utmost nicety, and to 
employ local remedial measures with intelligence and accuracy. The ap- 
paratus usually employed for laryngoscopic examination comprise : first, a 
lamp yielding a steady, bright flame provided with some form of reflector 
or condenser ; second, a circular concave mirror, from 3 to 3^- inches in 
diameter, and with a focal length of 12 or 14 inches, which should be 
freely movable in all directions upon its support, and should either be 
fixed to the forehead immediately above the eye by means of an elastic 
band, or attached to a spectacle frame and adapted to the right eye — in 
the latter case it should be provided with a central perforation of an oval 
form ; third, a laryngeal mirror of metal or silvered glass, of circular, oval, 
or quadrilateral form, and varying in diameter from half an inch, for a 
young child, up to an inch, fixed at an angle of about 120° to a thin 
metallic stem or shank, which should itself be fastened into an ivory or 
wooden handle. The entire length of the combined shank and handle 
should measure from 6 to 8 inches. In making an examination, the 
patient should be seated in front of the examiner, with his head inclined 
a little backwards ; the lamp should be placed at the side of, and somewhat 
behind, his head ; and the examiner should so arrange himself that his eye, 
with the mirror adapted, should be at the distance of about a foot in front 
of the patient's mouth. The mirror should be so adjusted as that the light 
which it reflects may be brought to a focus at about the back of the patient's 
uvula. He should then be directed to open his mouth widely and to pro- 
trude his tongue ; the point of which should be firmly grasped and firmly 
but gently drawn forwards by the forefinger and thumb of the operator's 
left hand, enveloped in a cambric handkerchief or tow r el. Then, the area 
of reflected light being steadily kept upon the point previously indicated, 
the laryngeal mirror (which has been previously w r armed either over a 
lamp or by immersion in hot water, in order to prevent the condensation 
of the patient's breath upon it) is to be carefully passed backward until it 
reaches the base of the uvula, in which situation it must be held, with its 
surface facing downwards and forwards, at an angle of about -45° with the 
horizontal plane of the mouth. If the upper orifice of the larynx be not 
at once seen in the mirror, the direction of the face of the mirror may need 
a slight alteration, or it maybe necessary to press the mirror a little further 
upwards and backwards, or otherwise to modify its position. It is import- 
ant, in order that the examination be satisfactory : first, that both patient 
and operator be patient and steady ; second, that no needless force be em- 
ployed to draw the tongue forward, and that it be not injured by undue 
pressure against the low T er teeth ; third, that in introducing the mirror, 
neither the tongue nor the palate be touched by it, excepting of course 
only that part of the palate against which it has to rest ; and fourth, that 
no single introduction be of long duration. It is best, usually, to repeat 
the operation several times in the course of a sitting. It need scarcely be 
added that many difficulties present themselves to interfere with the suc- 
cess of laryngeal inspection, some of which render inspection impossible, 
while others may be overcome with a little patience and delicacy of mani- 
pulation. 

Even if the condition of the larynx be healthy, we may in some cases 
perceive only the epiglottis and the tips of the cornicula laryngis. In more 
successful observations, however, w r e may detect not only these bodies but 



INVESTIGATION BY SIGHT AND TOUCH. 



337 



all the other boundaries of the superior orifice of the larynx, including the 
aryteno-epiglottidean folds, the cartilages of Wrisberg, the posterior com- 
missure, together with the rima glottidis, the true and false vocal cords, 
and if the rima glottidis be open sometimes the tracheal cartilages, and 
even the bifurcation of the trachea. All parts of the larynx, except the 
edge of the epiglottis and the true vocal cords, have a reddish hue, like 
that of the interior of the mouth, gums, or lips, the redness being usually 
brightest in the false vocal cords, in the cushion of the epiglottis, and over 
the cornicula and cartilages of Wrisberg. The vocal cords are pearly- 
white, the edge of the epiglottis, and, it may be added, the tracheal and 
the cricoid cartilages distinctly yellowish. 

It is always important to observe the movements of the vocal cords, and 
to examine the larynx both when the rima is fully open and when it is 
perfectly closed. The rima is always more or less widely open during 
ordinary quiet respiration ; but, in order to have it as widely open as pos- 
sible, the patient should be directed to draw a deep breath. In order to 
effect closure, he should be required to utter a vocal sound. The best for 
this purpose, as requiring for their pronunciation the greatest expansion of 
the oral aperture and cavity, are the vowel sound which is sometimes 
termed ' ur vocal,' and is uttered in the words 'cur' and 'myrrh,' and the 
broad sound of 'a' represented by 'ah.' 

The morbid conditions for which we should mainly look are swelling, 
congestion, ulceration, and exudation, such as may be caused by inflam- 
mation, diphtheria, syphilis, or other morbid processes ; warty or other 
growths ; paralytic or spasmodic affections of the vocal cords ; and com- 
pression of the trachea by aneurismal or other tumors. 

As regards the examination of the larynx and trachea from without, 
the chief points which are ascertainable are: first, the presence of tender- 
ness ; second, deviation of the trachea from the middle line, which may 
be due to tumors either in the neck or within the thorax ; and, third, in- 
filtration and thickening of the soft parts around. Thus, in inflammatory 
affections of the larynx, especially in cases in which the cartilages are in a 
state of necrosis, thickening with induration of the surrounding tissues is 
often a very remarkable feature ; and still more remarkable is the stony 
induration of parts and the fixation of the larynx which attend some cases 
of carcinomatous or other malignant infiltration. 

2. Chest — The form of the chest is often indicative of the presence of 
disease within. It must not be forgotten, however, that its general form 
varies widely in different individuals, sometimes from inheritance, some- 
times from rickety tendency during early life ; and that want of symmetry 
is often traceable to the preponderating use of the right hand, or to spinal 
curvature. But such varieties are quite independent of pulmonary affec- 
tions, and we must be careful not to confuse them with those which are 
attributable to the latter causes. 

General expansion of the chest is a common characteristic of patients 
who have suffered for many years from chronic bronchitis or asthma, espe- 
cially if there be at the same time pulmonary emphysema. Partly in 
consequence of long-continued over-exertion of the inspiratory muscles, 
partly from the difficulty which emphysematous lungs have to get rid o>t 
their surplus air, the chest increases in both its antero-posterior and its 
lateral dimensions, and assumes a rounded or ' barrel-like' form. If such 
changes begin in early infancy, it is not unusual to find that, while the 
upper part of the chest becomes generally expanded,, the lower zone (owing 
22 



338 



DISEASES OF THE RESPIRATORY ORGANS. 



to the comparative weakness of the ribs in early life) undergoes more or 
less contraction. It is seldom that the causes here spoken of operate on 
one side of the chest only. General enlargement of one side may be 
caused by accumulation of serum, pus, or air in the pleural cavity. In 
such cases the intercostal spaces get widened, the intercostal depressions 
effaced, and sometimes (especially if the effusion be inflammatory) replaced 
by actual bulging. Under such circumstances, undulation or fluctuation 
may occasionally be detected. In cases in which a lung is wholly or in 
the greater part of its extent pneumonic, the affected side remains fixed 
in the position of full inflation. Localized enlargements, or bulgings, may 
be the result of localized accumulations of air or fluid, or of the presence 
of aneurismal, sarcomatous, or other varieties of intra-thoracic tumors. 
In cases of empyema it is not uncommon for the pus to find its way be- 
tween the ribs, to form an accumulation between them and the integu- 
ments, and thus to cause a localized swelling. 

Contraction of the thoracic walls is exceedingly common; but it is 
rarely general and symmetrical, unless it be due to natural conformation, 
or the consequence of rickets, or of diseases like hooping-cough attended 
with long-continued impediment to inspiration. It is of chief clinical 
interest when it is unilateral or limited to definite regions. All pulmo- 
nary diseases, attended with diminution in the size of the lung, are attended 
with more or less marked contraction corresponding to that diminution. 
The most remarkable example is furnished by empyema or hydrothorax 
which has caused complete and permanent collapse of the lung. With the 
absorption or removal of the fluid the affected side gets reduced in all its 
dimensions, but especially flattened from before backwards, and the patient's 
carriage comes to resemble that of a person suffering from lateral curva- 
ture of the spine. Atelectasis, apneumatosis, cirrhosis, and the contrac- 
tion of cavities are all attended with more or less manifest contraction of 
that area of the chest-walls which corresponds to the portion of the lung 
involved ; but the most frequent, and on the whole the most important, of 
these localized contractions is that which is so commonly observed beneath 
one or both clavicles during the progress of phthisis. 

The movements of the chest are often very significant. The violent 
muscular efforts, yet little movement of the ribs, which mark the respi- 
ratory acts of emphysematous patients with barrel-shaped chests are very 
characteristic. The entire quiescence or little comparative movement of 
the affected side in cases of effusion into the pleura or of pneumonic con- 
solidation, and of the apex of the lung in cases of phthisis, is equally 
matter of interest and clinical importance. 

Whenever grave notes are uttered by the voice a distinct vibratile thrill, 
the vocal fremiti s, may be felt , not only over the larynx and trachea, but 
over the face and head, and over the wiiole of the surface of the chest to 
which lung-tissue is subjacent. The best mode of detecting this thrill in 
the chest is to place the palm of the hand flat and firmly on the part 
selected for examination. The degree in which it may be perceptible 
varies greatly in different persons, in dependence partly on the pitch and 
strength of the voice, partly on the quantity of muscle or fat present in 
the parietes of the chest. It is generally best recognized in male adults 
with spare frames. For obvious reasons it is more perceptible at the upper 
part of the chest, in front and between the scapulae, than elsewhere ; and 
it is either absent from the area of cardiac dulness, or comparatively feeble 
there. It is said to be a little more marked on the right than on the left side 



INVESTIGATION BY PERCUSSION AND AUSCULTATION. 339 



of the chest, but the difference is at most trivial ; and it may be regarded as 
a general rule that, with the exceptions referred to, it is present in an equal 
degree at corresponding parts of the two sides of the chest. The presence of 
disease largely modifies the intensity and distribution of the vocal fremitus. 
Whenever there is fluid effusion into the chest, the thrill becomes greatly 
enfeebled or absolutely annulled over the surface to which the fluid is sub- 
jacent. Whenever, on the other hand, lung-tissue is consolidated by 
pneumonia, the vocal fremitus over the affected region is much intensified. 
It must be added that mere thickening of pleura or accumulation of solid 
lymph in its cavity, acts equally with fluid effusion in damping vocal fre- 
mitus ; that solid growths, whether in the lung or external to it, have a 
like effect ; and that in rare cases fremitus is diminished even over pneu- 
monic lung. The explanation of the diminution of vocal fremitus in the 
several cases above enumerated is sufficiently obvious. The intensification 
which attends most cases of pneumonia is due apparently to the concur- 
rence of two conditions — the one, consolidation of the vesicular tissue 
which increases its capability of conducting sounds ; the other the permea- 
tion of the solid mass by pervious tubes along which the vocal vibrations 
are carried into its midst. 

In support or correction of the judgments formed from the results of 
visual or manual examination, it is always well to have recourse to actual 
measurement of the chest, or of portions of it, and of the amount of ex- 
pansion or movement which they undergo. It is needless to describe in 
detail how all such measurements are to be effected ; it is sufficient, pro- 
bably, to name the chief instruments which may be used for the purpose, 
namely, the measuring-tape and calipers, and the cyrtometer. 

The last name is applied to a metal wire, or specially devised band, 
which admits of close adaptation to the surface of the chest, and retains 
its form after removal, so as to allow of a tracing being made from it. 

Spirometer — It is sometimes useful to ascertain what Dr. Hutchinson 
calls the ' vital capacity' of the chest by means of an instrument made on 
the principle of the gasometer, which he terms the ' spirometer.' He 
measures this capacity by the amount of air which a person who has dis- 
tended his chest to the utmost is able to discharge by voluntary expiratory 
effort. This amount appears to be very constant in relation to stature. 
Thus, the average vital capacity of a man five feet seven inches high is 
about 225 cubic inches, and for each inch of stature above this there is an 
increase, and for each inch below it a decrease of about eight cubic inches. 
It is often difficult to make persons under examination exert a sufficient 
effort to manifest their true vital capacity ; but if after having done so 
there is any wide departure from the scale above given there is good reason 
to suspect the existence of some morbid condition, either involving the 
lungs, or interfering with the due performance of the respiratory acts. 
The vital capacity of women is much less than that of men. 

T>. Investigation by Percussion and Auscultation. 

Of all the aids to the recognition of the morbid processes which are 
going on within the thorax none is so important as the employment of 
percussion and auscultation — both, methods of investigation scarcely 
thought of prior to the commencement of the present century, but which, 
within the last fifty years, have been largely cultivated and have furnished' 
the most valuable results both to the physiologist and to the physician. 



340 



DISEASES OF THE RESPIRATORY ORGANS. 



1. By percussion is meant the investigation of the condition of internal 
organs by the sounds which are yielded by sharply striking the surfaces 
over them. There are three principal methods by which this may be 
effected, namely : 1st, by striking the surface directly either with the fist, 
the knuckles, or the tips of two or three fingers brought together into the 
form of a hammer, or by simply filliping with the nail of the forefinger ; 
2d, by the use of the hammer and pleximeter — the pleximeter is a small 
thin ivory disk which, for the purpose of receiving the blow of the ham- 
mer, has to be laid firmly and flat upon the surface of the part to be per- 
cussed ; the hammer, which usually has a comparatively heavy metallic 
head, is furnished at its striking extremity with an India-rubber pad, which 
alone comes in contact with the pleximeter, and prevents the development 
of any sound special to the instrument ; 3d, by the employment of the fore 
or middle finger of the left hand as a pleximeter, and the tips of one, two, 
or three fingers of the right hand as a hammer ; in this case the finger of 
the left hand should be laid firmly and flat, with its palmar surface down- 
wards, on the surface to be examined, and the tips of the striking fingers 
of the opposite hand should be brought down perpendicularly and sharply 
upon it. The first of these three methods of percussion has fallen into 
almost entire disuse, chiefly because of the needless pain which it is apt to 
inflict; still it may sometimes be employed with great advantage — and 
especially the method of filliping with the forefinger — when, as in the 
chest of young children, and in the exploration of the abdomen, even 
slight pressure of the pleximeter is liable to displace air or fluid, the pre- 
sence or absence of which at some particular point it is important to deter- 
mine. The second method is a valuable one, especially for clinical teach- 
ing, because the sounds which it evolves are loud and readily distinguishable 
by a class of students. The third method is that which is in general use, 
partly because of its great convenience, and partly, because, although the 
sounds which are elicited by it are comparatively feeble, they are perfectly 
appreciable. It may be noted here that, whenever it is sought to compare 
by percussion the corresponding parts of opposite sides of the trunk, it is 
most important that for each pair of examinations the pleximeter, whether 
the finger or the disk, should be symmetrically placed, and the force and 
direction of the blows should correspond ; and, further, that it is import- 
ant as far as possible to prevent any sound due to the instrument itself 
from interfering with that elicited from the part percussed. 

a. Normal 'percussion phenomena.. — The sounds which are yielded to 
percussion by the healthy chest are of two kinds, resonant and dull. 
These words are by no means well-chosen, but they are sanctified by long 
and general usage, and would be difficult to replace. By resonance we 
mean to imply the presence of more or less musical quality, by dulness the 
absence of such quality. 

i. Resonance. — A resonant sound is yielded by all those parts of the 
chest- walls which are by their deep aspect in contact with lung, and by 
that part of the left half of the chest to which the stomach is subjacent. 
The quality of the resonant sound which is evolved on percussing the 
pulmonary regions of the thorax is difficult to describe, but sufficiently 
characteristic to be easy of recognition when once it has been heard. It 
is somewhat deep in tone, short in duration, and vaguely musical. It 
differs, however, in some degree in quality in different parts of the chest, 
and considerably in different individuals. Hence it is important, in judg- 
ing of the significance of percussion sounds, not to assume the existence of 



PERCUSSION. 



341 



a normal standard sound with which all others must be compared, not to 
compare the resonance of one person's chest with that of another, nor, 
indeed, to compare indiscriminately the resonance of different parts of the 
same individual's chest. But we should carefully compare the sounds 
yielded by the corresponding points of the two sides of the chest. The 
chief cause of the resonant quality of the percussion note is the vibration 
of the struck walls which is permitted by the fact that an elastic medium 
— the air — is situated on either side of them. It is obvious, however, that 
the elasticity of the inflated lungs is less than that of the free atmosphere 
outside, and that hence the vibration of the thoracic walls must be to some 
extent less perfect than it would be were the air on both sides equally free 
to move. The sound, we repeat, is mainly due to the vibration of the 
thoracic walls alone ; but it is difficult (owing to the somewhat irregular 
form and structure of these walls, and to the interference with their vibra- 
tion caused, on the one hand, by the solid organs which lie here and there 
beneath them, and, on the other hand, by the junctions of the chest with 
the upper extremities) to determine to what extent and in what manner 
these vibrations are effected. It seems resonable, however, to assume that 
so much of each half of the thorax as bounds lung-tissue vibrates bell-like 
when any part of that half is struck, and that the impure musical sound 
which is elicited comprises a fundamental note due to the vibration of the 
whole or a large portion of the side, and harmonic tones due to the vibra- 
tion of aliquot parts of it. This view is entirely compatible with the fact 
that percussion notes of somewhat different quality are yielded on striking 
different parts of the surface, and, if correct, makes it obvious that the 
sound elicited by the percussion of any spot is by no means necessarily 
indicative of the condition of the lung-tissue immediately beneath it. It 
must be added that some, though a very variable, quantity, of thoracic 
resonance is independent of the presence of air beneath the chest-walls. 
Thin and elastic bones, even if they be imbedded in solid tissue, vibrate 
sensibly when percussed. A sound which is not absolutely dull may be 
obtained by percussing the bones of the skull ; and some degree of reso- 
nance may always be elicited over the sternum even when no lung-tissue 
is subjacent to it. The ribs, also, especially if the patient be thin, usually 
yield a somewhat resonant sound. 

The stomachal resonance may always be recognized (though variable in 
extent, distinctness and quality according to the degree of distension of the 
organ with gas and to the level which it attains within the cavity of the 
thorax) at the lower part of the left side of the chest, both posteriorly, 
laterally, and in front, but chiefly in the last two situations. It may readily 
be distinguished from the normal lung-resonance by its much more dis- 
tinctly musical character, by its purer tone and generally higher pitch. 
The sound is often termed tympanitic, or drum-like. 

ii. Dulness — Absence of resonance, or dulness, is observable on per- 
cussing the precordial region, and that part of the right side of the chest 
between which and the liver no lung-tissue intrudes. This sound, again, 
can be better appreciated by a single experiment than by any description. 
It may be described as short, somewhat sharp, and unattended with any 
appreciable ring or tone. The feeble sound elicited by the percussion of 
the thigh is often referred to as the very type of a so-called ' dull' sound. 
It differs, however, materially from that which is yielded by the precordial 
region. And, indeed, the quality of dulness, in the clinical sense, presents 
many varieties, and passes by insensible gradations into that of resonance. 



342 



DISEASES OF THE RESPIRATORY ORGANS. 



Many so-called dull sounds become obviously musical when tested stetho- 
scopically. 

b. Abnormal percussion phenomena. — Percussion in cases of pulmonary 
disease is mainly of use in enabling us to acertain the presence and define 
the limits of consolidation, pleural effusion, and morbid growths, and of 
conditions causing extension or modification of resonance. 

i. Dulness Whenever any considerable mass of lung-tissue is rendered 

solid, either by tubercular infiltration, by inflammatory deposit, by effusion 
of blood, by carcinomatous growth, or in any other way, all that area of 
the chest-wall on which it abuts loses its normal resonance and becomes 
more or less dull. The presence of fluid in the pleura causes dulness in 
even a more marked degree up to the level of the effusion. The recog- 
nition of the cause of dulness must depend partly on the situation, extent, 
and form of the area of dulness, partly on a variety of considerations, the 
collective significance of which will be more conveniently discussed here- 
after. It may be mentioned, however, that pneumonic consolidation usually 
occurs in the lower part of the lung, tubercular infiltration at the apex, 
and that pleuritic effusion, unless it be circumscribed by adhesions, or so 
abundant as entirely to compress the lung, may often be recognized by the 
changing level of the upper limit of dulness in accordance with the different 
positions which the patient's trunk is made to assume. But although 
marked dulness is always present when consolidation is extensive and con- 
tinuous, it is often absent, or at all events scarcely appreciable, when either 
an extensive Jiract of lung-tissue, uniformly contains more solid matter or 
fluid and less air than natural, or miliary or larger nodules of solid tissue, 
separated from one another by a network of crepitant tissue, or even thickly 
distributed. Thus congested or oedematous lungs, and lungs in the early 
stage of inflammation, on the one hand, and lungs which are the seat of 
disseminated tubercles or of lobular pneumonia on the other, are not un- 
frequently so strikingly resonant as utterly to deceive the too confiding 
percussor. 

ii. Resonance — It is obvious that, whenever there is any extension of 
the area of dulness, there must be a corresponding diminution in the area 
of resonance. On the other hand, the normal areas of thoracic dulness are 
not very unfrequently reduced or effaced by the extension of resonance. 
In association with such changes, and sometimes indeed apart from them, 
the resonance of the resonant area is altered in intensity, quality, or pitch. 
To denote different varieties and degrees of resonance many terms have 
been employed — such, for example, as wooden, leather-trunk-like, tubular, 
cavernous, tympanitic, high-pitched, and the like. Some of these are 
obviously fanciful, some indicative of a foregone conclusion with regard 
to the case under examination; but others do, to some extent, explain 
themselves, are applicable and convenient. Augmentation of resonance 
(to which condition the epithet '•tympanitic' is sometimes given) may often 
hd heard over emphysematous lungs, or lungs distended (as they sometimes 
are in cases of acute bronchitis) with air, but especially over a pleural 
cavity the seat of pneumothorax. It should be added, however, that in 
such cases the augmentation of resonance is for the most part attended 
with the production of a purer note, and frequently a note of somewhat 
higher pitch, than characterizes the normal chest-resonance of the patient. 
But augmented resonance, with change of quality and pitch, is often heard 
under very different conditions from those which have just been considered. 
It is frequently observed, for example, that in cases of extensive pulmonary 



PERCUSSION. 



343 



consolidation, or pleural effusion, of one side, the crepitant remnant of lung- 
tissue evolves under percussion a much purer note than the corresponding 
part of the opposite lung. The sound is sometimes described as being more 
resonant than that yielded by the opposite side ; possibly it may be so, but 
it is at all events more distinctly musical, and always of considerably 
heightened pitch. Not unfrequently indeed the sound is almost exactly 
like that produced by percussing a portion of small intestine or striking 
one of the treble keys of the piano. This modified resonance is most fre- 
quently observed over the apex of the lung when the rest of the organ is 
consolidated or compressed^ but by no means necessarily occurs only in 
that region ; and may sometimes be distinctly heard over portions of pneu- 
monic lung which are not yet completely solidified. Various explanations 
of the phenomena here described have been given. With respect to the 
increased resonance which attends pneumothorax, emphysema, and the 
like, it will probably be admitted that it is due to the more ready and 
perfect vibration of the thoracic walls which the relative increase of air 
beneath their inner surface permits. This explanation, however, will 
scarcely apply to the higher pitch which the percussion note usually then 
acquires, and is certainly not applicable to those cases in which high-pitched 
resonance occurs over partly consolidated lung, or lung in the neighborhood 
of consolidated tissue. Reverting to the explanation we have already given 
of the ordinary resonant sound yielded by the thoracic walls (namely, that 
in its production all those parts of the thoracic walls which are in contact 
with the lung under examination vibrate, bell-like, producing a somewhat 
obscure assemblage of fundamental and harmonic tones, the general effect 
of which is deep in some sort of proportion to the extent of surface which 
vibrates) ; and knowing that (other things being equal) the smaller a 
vibrating area becomes the higher will be the fundamental tone it yields ; 
and seeing that such a diminution of vibrating area necessarily takes place 
when there is extensive consolidation or fluid effusion, and not improbably 
occurs in the first stage of pneumonia over the affected portion of lung ; it 
seems reasonable to assume that mainly in these considerations is to be 
sought the explanation of the acoustic phenomenon in question. It must 
not be forgotten, however, that the increase of tension, which in pneumo- 
thorax, and in a less degree in pleurisy with effusion, the thoracic walls 
experience, also tends to the production of a higher note. 

The question ' how far can the percussion note be modified by conditions 
within the chest other than those which have been discussed?' still remains 
for consideration. Can it, for example, be affected by the neighborhood 
of solid matter separated from the parietes by a layer of crepitant tissue? 
Can it be modified by the internal resonance of cavities which abut upon 
the surface? The former of these questions has been answered in the 
affirmative by most writers ; who assert that, by regulating the force of the 
percussion stroke, the resonance due to the intervening lung and the 
dulness due to the subjacent solid structure, can be distinguished, and that 
thus the extension of the heart beneath the thin edge of the lung, and the 
ascent of the liver behind the lower margin of the right lung, can be easily 
detected. We confess we are not satisfied of the general truth of this 
assertion. We may remark, however, as bearing upon it — that the quality 
and power of a musical tone differ according to the part of a vibrating cord 
or surface w T hich is struck, and that hence the quality and power of per- 
cussion tones are doubtless modified as we pass from the centre of a reso- 
nant area to its margins; and again that it is quite possible in the yielding 



344 



DISEASES OF THE RESPIRATORY ORGANS. 



chests of young children, if undue pressure be made by the pleximeter, to 
compress or displace the thin edge of the lung lying between the heart or 
liver and the parietes, and so to obtain dulness, where normally resonance 
should be elicited. But this is the consequence of pressure and not of 
percussion. As to the latter of these questions, there is no doubt, that if 
auscultation be practised at the same time as percussion, the resonance due 
to a subjacent large cavity may occasionally be recognized in the form of a 
superadded musical twang. There is, however, one variety of percussion 
sound which certainly owes its peculiarity to the conjunction of a sound 
produced within the chest, with that due to the vibration of the thoracic 
Avails, namely, the bruit de pot file, or cracked-pot sound — a sound which 
may be almost exactly simulated by clasping the hands crosswise and then 
striking the back of one of them sharply against the knee-cap. The ' chink' 
which distinguishes it appears to be due to the sudden compression of a 
portion of lung-tissue and the sharp expulsion of the air which it contained 
with an audible hiss through the bronchial tubes. To produce the sound 
the percussion stroke must be forcible, and made while the patient is ex- 
piring with his mouth open. It is chiefly producible in the front of the 
chest, either at the apex or in the mammary region. It may indicate the 
presence of a cavity in the lung, but is more commonly produced in the 
healthy chests of young children owing to the great yieldingness of their 
thin thoracic parietes, and in patients suffering from pneumonia or pleurisy 
in association with the high-pitched resonance so often present. 

c. Resistance One further indication of importance often furnished by 

percussion is the presence of unyieldingness or resistance. In the percus- 
sion of healthy chests the resilience of the parietes can always be in some 
degree appreciated ; it is indeed so constant and essential a factor of the 
process that on that very account it may escape observation. But in cases 
of solid growths in the cavity of the thorax, and in cases even of pleurisy 
with much thickening of pleura and much distension, the rigidity of the 
thoracic walls over some limited area, and their total want of elasticity and 
of yieldingness are quite remarkable and unmistakable. 

2. By auscultation is meant the process of listening, either by applying 
the ear directly to the surface, or by the aid of some conductor, to sounds 
evolved within the body. The direct application of the ear to the surface 
is in some respects preferable to any other mode of auscultation. Many 
sounds are thus heard much more distinctly than they otherwise would be 
heard; and some delicate but distinctive sounds are wholly lost in their 
passage along a conducting rod or tube. But, on the other hand, the 
naked ear cannot be applied with ease to all parts which it is desirable to 
auscultate, nor can we by its aid limit our examination with precision to 
minute areas. The objections on the score of delicacy and cleanliness are 
sufficiently obvious. 

The instrument which is employed to convey sounds produced within 
the body to the ear of the observer is termed the ' stethoscope.' Of this 
innumerable forms and varieties have been invented and are in use. As 
to material, they have been made of bone, ivory, silver, gun-metal, gutta- 
percha, and different kinds of wood; as to form, they are always cylindrical 
in the whole or greater part of their extent — in the latter case being pro- 
vided at one end with a circular disk to fit the ear, at the other end with 
a conical expansion, the circular base of which is to be applied to the part 
under examination. Further, they are made of different lengths, some- 
times solid thioughout, but generally with a cylindrical channel running 



AUSCULTATION. 



345 



through the stem from the ear-piece downwards to the conical enlargement, 
where it undergoes a corresponding dilatation. The material, the length, 
and the general form of the instrument are matters of very little real 
importance. The great desiderata are that it should be light and portable, 
that the ear-piece should be one that readily adapts itself to the ear of its 
possessor, and that the conical enlargement at the opposite end should 
be of medium size, and that (if provided with an opening) its margin 
should be sufficiently broad and rounded to admit of its adjustment without 
causing pain. 

There are certain peculiarities in the acoustic properties of stethoscopes 
which it is well to be aware of. Solid stethoscopes undoubtedly convey 
sharp impulsive sounds and musical notes with great intensity ; but they do 
not transmit the respiratory rustles and other feeble and unmusical sounds 
with anything like the distinctness with which the hollow stethoscope con- 
veys them. The difference is very much that existing between a speaking- 
tube which readily transmits the whispered voice, and a solid rod which, 
with the aid of a sounding-board, reproduces at a distance the full music 
of a piano with which its opposite extremity is in contact. The hollow 
stethoscope, however, combines in itself the properties of both, and is 
therefore the preferable instrument for common use. Again, it is indispu- 
table that certain sounds are much more distinctly audible with some 
hollow stethoscopes than others ; and that this fact is, in some instances, 
due to differences in the length of the instruments. The explanation ap- 
pears to be that the tubes of stethoscopes consonate, according to their 
length, with certain definite notes and certain of their harmonics. 

Besides the simple varieties of stethoscope above considered, there are 
two others which are often of considerable service. These are the binaural 
and the differential stethoscopes. In the former, which was invented 
by Dr. Leared, the stem arising from the conical end divides into two 
branches, the points of w r hich respectively fit into either ear. Both ears 
are thus equally engaged in listening to the sounds emanating from the 
area under examination, which are hence intensified and on the whole more 
easily appreciated. The other form of stethoscope is also binaural in the 
sense that there is an ear-piece for each ear, and both ears are engaged ; but 
the tubes which are prolonged from the ear-pieces remain distinct from one 
another and terminate each in a conical expansion. The advantage of this 
arrangement is that by it the auscultator is enabled to hear and determine 
the synchronism or asynchronism of sounds which are developed at dif- 
ferent spots. 

In using the stethoscope, it is of essential importance that (if it be hol- 
low) its lower end should rest evenly on the surface to which it is applied, 
that the ear-piece should be adjusted accurately to the ear, that nothing 
whatever should be in contact with the instrument save the ear of the aus- 
cultator and the surface under examination, and that there should be no 
rustling or friction or other noises in connection with the patient's skin or 
clothes. It is always best to listen to the naked skin ; and, if covering be 
necessary, it should be as thin as possible and in one layer only. Further, 
it is sometimes well to close the opposite ear against extraneous sounds. 

a. Normal auscultatory phenomena The sounds audible through the 

stethoscope applied over the healthy respiratory organs are those of respi- 
ration, articulation, and phonation. In morbid conditions of these parts, 
the acoustic phenomena attending the several acts referred to become 



346 



DISEASES OF THE RESPIRATORY ORGANS. 



variously and often largely modified, and others of a totally different kind 
are often superadded. 

i. Auscultation of the breath — If we apply the stethoscope to the larynx 
or trachea during ordinary respiration, a somewhat harsh blowing sound 
is heard to accompany both the act of inspiration, and that of expiration. 
The sound is like that of the loudly-whispered vowel represented by the 
syllable ' ur,' or like the whispered consonantal sound of the letter w. Each 
sound lasts as long as the act which produces it, is uniform in character 
throughout, begins and ends abruptly, and is separated by an obvious 
though very short interval from the sound which follows it. That which 
attends inspiration is somewhat sharper and louder than the other, and both 
may be increased or diminished in intensity by varying the force of the 
respiratory movements. The sounds are almost certainly developed at the 
narrowest part of the tube, namely the rima glottidis, by the rustle which 
its interference causes in the current of air passing through it. The slight 
but obvious differences in quality and force which distinguish them from 
one another are hence explicable ; the sound produced at the rima being 
carried inwards with the inspiratory current, outwards during expiration. 
Ordinarily, the sound attending expiration is more audible to one's self and 
to bystanders than that attending inspiration. The sounds here described, 
though somewhat modified in character, are in general still audible over 
the manibrium of the sternum, and between the scapulae, at and above the 
level of the roots of the lungs. 

Over the lungs themselves the sounds which attend the respiratory move- 
ments are of a very different character from the above. The inspiratory 
sound is difficult to describe : it has a kind of rustling character, and is 
feebler and of lower pitch than the corresponding tracheal murmur ; the 
expiratory sound is often absent, and when present is still feebler and lower 
in tone than the inspiratory sound. Moreover, the two sounds, instead of 
presenting uniform intensity throughout, and being separated by a distinct 
interval from one another, commence and die away so gradually that they 
seem like mere pulses of a continuous murmur. The healthy pulmonary 
sounds vary a good deal in intensity, and, in some degree, in quality in 
different individuals; there are also slight differences between them as 
heard at different parts of the same chest; and not unfrequently, especially 
at the apex, the sound towards the end of a deep inspiration assumes an 
indistinctly crepitating character. What is the cause of the sounds? That 
they are not made in the larger air-passages, and conveyed through the 
spongy tissue of the lungs to the surface, seems clear from the fact that in 
those cases where, from contraction of the larynx, trachea, or bronchial 
tubes (as in laryngitis, pressure of an aneurism, and asthma), a peculiarly 
intense noise is made in these canals during respiration, the pulmonary 
murmurs, instead of being correspondingly augmented, are diminished or 
actually suppressed. The ordinary explanation is doubtless the correct 
one, namely, that they are produced in the minuter air-passages and air- 
cells by the passage of air to and fro in them, and by the changes of form — 
the movements — which these parts undergo. 

ii. In auscultating the voice, it is important to recollect the fact that 
phonation takes place — the music of the voice is manufactured — at the 
rima glottidis by the vocal cords ; that articulate sounds are formed only 
in the cavity of the mouth, by means, " chiefly, of the lips, tongue, and 
palate. If the larynx or trachea be examined stethoscopically during the 
act of speaking aloud or singing, the musical notes which are evolved are 



AUSCULTATION. 



347 



conveyed through the instrument to the ear with almost painful force ; 
similar sounds, diminished somewhat in intensity, are also audible over 
the manubrium of the sternum and between the upper parts of the scapulas 
behind. They are still audible, but with much less force, over the whole 
of those portions of the chest which have lung-tissue subjacent to them. 
The sounds are usually somewhat more intense above than below, in front 
than behind, and at the lower part posteriorly sometimes present, even in 
health, a somewhat bleating character. The degree in which vocal re- 
sonance or bronchophony is audible varies in different individuals, chiefly 
in dependence on the pitch and quality of the voice. Thus it is, as a rule, 
more obvious in those who have a deep voice than in those whose voice is 
high, and in men therefore than in women or children. It may be added 
that it is often distinct when vocal fremitus is quite imperceptible, and that 
in some individuals it scarcely exists at all. The articulate voice is always 
best distinguished when the patient speaks in a whisper ; words thus ut- 
tered are distinctly transmitted through the stethoscope applied to the wind- 
pipe in the neck, or along its course in the thorax, or over the situation of 
the bronchi ; they may also occasionally be heard over the apices of the 
lungs of healthy persons, especially children. This phenomenon is termed 
4 pectoriloquy.' 

b. Abnormal ausculatory phenomena The respiratory sounds are often 

much modified in disease. We have adverted to the fact that they are 
frequently not only greatly diminished, but actually absent, in certain 
cases of obstructive disease of the larger air-passages ; they are enfeebled 
also whenever the respiratory movements are themselves feeble, and are 
generally much weakened or even annulled where the lung is compressed, 
consolidated, displaced, or where fluid, air, or solid matter lies between it 
and the thoracic walls. On the other hand, the respiratory sounds are 
necessarily intensified whenever the acts which produce them are unusually 
vigorous. It is due, doubtless, to this cause alone that they may often be 
heard with preternatural loudness over the healthy lung of a patient whose 
other lung is pneumonic or compressed by pleural effusion. 

i. Tubular or bronchial breathing is a modification of respiratory sound 
frequently heard in lungs consolidated by pneumonia, compressed by pleu- 
ritic effusion, or containing smallish cavities, of whatever origin, imbedded 
in airless tissue. It almost exactly resembles the breath sounds audible 
over the trachea. The inspiratory and expiratory elements begin and end 
abruptly, are uniform throughout, and separated from one another by a 
distinct but short interval ; moreover the expiratory sound is somewhat 
deeper and less distinct than that of inspiration. They vary in quality in 
different cases and under different circumstances, but are generally higher 
in pitch than the tracheal sounds are. It is necessary, in order to their 
full development, that the respiratory acts be moderately forcible, that the 
air-tubes of the portion of luns; under examination be not completely 
obstructed, and that they do not contain mucus or other matters which are 
productive of crepitating and other such adventitious sounds. Hence, in 
pneumonia, tubular breathing may be absent or incapable of recognition if 
the bronchia be blocked up with casts ; in pleurisy, if the compression of 
the lung be so great as to involve the obliteration of the tubes ; in pul- 
monary excavation, if the vomicae have no free connection with the air- 
channels ; and in all such affections when the cavities or tubes are loaded 
with mucus or other fluids. Various' explanations have been offered of the 
production of tubular breathing. By some it has been held that the sounds 



348 



DISEASES OF THE RESPIRATORY ORGANS. 



heard over the affected portion of lung are simply those manufactured at 
the rima glottidis, conducted to the ear through the diseased tissues. 
Others consider that the tubular sounds are actually produced by the to- 
and-fro movement of air in the tubes of the diseased tract. While others 
again, with Skoda at their head, regard them as the laryngeal: sounds in- 
creased and modified by consonance in the bronchial tubes. An insupera- 
ble objection, it seems to us, to the truth of Skoda's explanation is the fact 
that consonance either increases the intensity of obvious musical tones, or 
develops an obvious musical tone from unmusical sounds or from vibrations 
which are musical in rhythm, but of themselves too feeble for the ear dis- 
tinctly to appreciate. But the tubular sounds heard over a pneumonic 
lung are no more musical than those heard over the trachea. An objec- 
tion to the second explanation resides in the fact that, in the majority of 
cases in which tubular breathing is heard, the affected lung-tissue neither 
expands nor contracts during respiration, so that there can be no to-and- 
fro movement of air in its tubes to cause the sounds which may be heard 
over it. The first explanation appears to us to be substantially correct, 
for the following reasons : the sounds of tubular breathing are like those 
produced at the rima glottidis during respiration ; there is no doubt what- 
ever that these, as well as all other sounds developed at this orifice, are 
readily conveyed, with little change of character, along the patent bron- 
chial tubes, as along so many small stethoscopes, towards their peripheral 
distribution ; the intensity of the tubular sound is proportionate, in great 
measure, to the intensity of the laryngeal sound, and indeed a distinctly 
tubular sound may, even in health, be developed and actually overpower 
the normal respiratory sounds when patients who are told to breathe deeply 
breathe noisily through the larynx. We are by no means prepared to 
deny that to-and-fro sounds, differing little from those originating in the 
larynx, may be produced by the to-and-fro movement of air in bronchial 
tubes connected with lung capable of respiration, and that such sounds 
may contribute in some cases to the collective result which we term tubular 
breathing. Whatever explanation be adopted, however, there is no doubt 
that the homogeneousness of texture which a consolidated or compressed 
lung presents allows, far more readily than normal spongy lung-tissue does, 
of the transmission of sounds which are developed within or conveyed into 
its substance ; and further, that the total suppression of the healthy respi- 
ratory murmur, which characterizes all those conditions of lung in which 
tubular breathing is heard, contributes importantly to its ready recognition. 

ii. Amphoric, cavernous, or metallic breathing. — These terms are em- 
ployed to designate the peculiar quality of sound which may sometimes be 
heard over cavities containing air, and usually communicating with the 
external atmosphere by means of the bronchial tubes or other passages. 
It consists in a peculiar metallic ring, or musical twang, following upon 
the respiratory or other sound which calls it forth. A closely similar 
twang attends the footfall of a person walking between high walls, or over 
a vault, and may be recognized in perfection if a child's India-rubber ball 
be placed in contact with the ear and then sharply tapped or filliped. The 
addition to any other intrathoracic sound of the musical prolongation here 
referred to is always indicative of the presence of a cavity containing air ; 
and it may sometimes be heard almost as distinctly in a cavity the size of 
a walnut as in one corresponding in capacity to the whole of the pleural 
sac. Its presence does not absolutely prove that there is communication 
between the cavity and the outer air, although in the great majority of 



AUSCULTATION. 



349 



cases such a communication does in fact exist ; nor does it prove that the 
cavity to which it is due is an abnormal cavity, for it may, when detected 
at the lower part of the left side of the chest, be referable to the stomach ; 
nor. again, does it necessarily throw light on the form of the cavity or the 
structure of its walls, although, for the most part, we have reason to suspect 
when we hear it that the cavity or some part of it is of a rounded form, 
and that the walls are somewhat smooth and elastic, or, at all events, of 
such a character as to allow of reverberation. The cause of this amphoric 
resonance is obviously the reverberation, or succession of echoes, which 
occurs between the opposite sides of the cavity when any impulse or sound 
capable of originating it reaches the air in its interior. The chief condi- 
tions under which amphoric resonance manifests itself in connection with 
cavities are the following : First, it attends the respiratory sounds, and 
more particularly that of inspiration. It is important, however, to observe 
that the respiratory sounds yielded from a cavity are, apart from the super- 
added resonance, tubular; and that if, from any circumstance, the musical 
twang be absent from them, there is nothing left by which they can be 
distinguished from ordinary tubular breathing. It is probably never pro- 
duced in this case unless the cavity communicates with a bronchial tube 
or by a fistulous opening with the external air ; and although it is probably 
not essential to its production that there shall be actual movement of air 
into and out of the cavity, there is no doubt that such movement tends 
largely to intensify it. Second, it attends both the sounds of vocalization 
and those of coughing. Third, it may be evolved over large cavities by 
percussion of the thoracic walls which bound them, and especially if the 
percussion sound be sharp and short, as it may be made by employing two 
coins — one as a pleximeter, the other as a hammer {bruit d'airain). Fourth, 
it gives a metallic quality to the various rales or rattles which are produced 
in them or in their vicinity by the passage of air through fluid. It should 
be noted, however, that short sharp sounds like those of ordinary largish 
crepitation more readily induce an audible echo than do the duller less in- 
tense sounds of respiration and the like ; and that hence crepitation often 
becomes metallic in small cavities, which give no such quality to respi- 
ratory, vocal, or tussive sounds, and sometimes even in the normal cavities 
of the bronchial tubes. Lastly, in large cavities we not unfrequently get 
that perfection of amphoric resonance which is termed ' metallic tinkling' ; 
a sound which is always most characteristically evolved in response to 
some sharp detonation, such as is produced by the bursting of a largish 
bubble or by the fall of a drop of fluid from above on to a surface of fluid 
below. 

The cavernous echo, although in many cases remarkably distinct and 
unmistakable, is in some cases so feeble that it fails to be transmitted along 
the ordinary stethoscope, and can be detected only by aid of the binaural 
stethoscope or by the ear applied directly to the chest. Further, it may 
be, and often is, effectually concealed by the intervention between the 
cavity and the thoracic walls of a layer, however thin, of crepitant lung- 
tissue. And, again, it is important to know that cavities of considerable 
size, especially if there be no communication, or only imperfect communi- 
cation between them and bronchial tubes, often yield no sound whatever 
due to themselves, and merely very feebly conduct tubular or even healthy 
respiratory sounds due to the lung-tissue in which they are imbedded. 

There are yet one or tw-o other sounds which may be developed within 
cavities, and may hence be included within the meaning of the term cav- 



350 



DISEASES OF THE RESPIRATORY ORGANS. 



ernous respiration. It is possible, for instance, that a cavity may be of 
such a size and shape as to be capable of resonating to some particular 
note; and that the production of that note by the patient in his larynx 
may be attended with special resonance within the cavity. And, again, it 
sometimes happens that when a cavity communicates, by a flap-like or 
valvular opening, with a bronchial tube, there is no sound audible over the 
cavity during ordinary respiration or during the early period of a forcible 
inspiration ; but that during the course of the latter the air rushes into the 
cavity with an audible click, hiss, or gurgling sound — a phenomenon which 
is repeated whenever the patient inspires deeply. 

iii. Bronchophony, pectoriloquy, and cegophony The terms pecto- 
riloquy and bronchophony have been employed with great laxity, even by 
those who assume to be authorities upon the subject of auscultation. It 
has been frequently asserted that bronchophony as it becomes more marked 
passes into pectoriloquy, as though the two conditions were mere grades of 
the same phenomenon. This, however, is certainly not the fact ; bron- 
chophony never becomes converted into pectoriloquy, although they are 
often associated ; loud bronchophony, indeed, drowns the pectoriloquy with 
which it may be associated ; and, in order to be certain of the existence 
of pectoriloquy, it is always best to eliminate the effects of bronchophony 
by making the patient speak in a whisper. As we have already pointed 
out, bronchophony is the offspring of laryngeal intonation, pectoriloquy of 
the articulate sounds developed within the cavity of the mouth. 

Bronchophony, in its pathological sense, means preternatural distinct- 
ness, or loudness, with little alteration of quality, of the laryngeal musical 
tones as conveyed to the ear through the tissue of the lung. Its intensity, 
as well in disease as in health, presents considerable variations. Hence 
in determining the presence or absence of abnormal bronchophony we 
must not be content to note that the voice-resonance is louder in one part 
than another; but we must observe whether it is relatively loudest over 
those parts of a lung in which normally it is comparatively feeble ; and 
especially we must be careful to compare the resonance of the voice in cor- 
responding parts of the two sides of the chest. Bronchophony is gene- 
rally developed over consolidated lung-tissue — pneumonic, tubercular, or 
other — and over the sites of vomicae And its development in abnormal 
situations is clearly due to the same combination of causes as that to which 
we have ascribed the phenomena of tubular breathing — namely, first, the 
conduction of the musical vibrations along the patent bronchial tubes or 
tubes and cavities, into the very substance of the consolidated tissue ; and, 
second, the ready transmission of these vibrations thence through this 
tissue to the surface of the chest. Skoda attributes bronchophony, as he 
does tubular sounds, to consonance of the laryngeal sounds within the 
bronchial tubes. We are far from denying that the tubes may consonate 
to musical sounds, or that they do so consonate in certain cases. But a 
tube of a certain definite length can only consonate to a certain definite 
note, and possibly to some of the higher harmonics of that note ; and 
assuming (what seems scarcely possible) that the length of tube capable 
of consonating is to be measured from the rima glottidis to the terminal 
part of a bronchial tube at the base of the lung — a length of about twelve 
inches — the lowest note to which it (being a pipe closed at both ends) 
could consonate would be one produced by undulations a foot long, or one 
lying between B and C of the treble clef. There are good reasons for be- 
lieving that the consonating note would be much higher. Now, if this 



AUSCULTATION. 



351 



explanation were true, the deeper tones of the voice, which are actually 
loudest in bronchophony, should be comparatively inaudible, and of acute 
tones one only, or one and some of its harmonics, should be conveyed to 
the ear. But this is certainly not the case. 

Pectoriloquy implies the conveyance through the stethoscope placed on 
the chest of the articulate utterances of the person auscultated, as though 
he were applying his lips to the instrument and speaking through it^into 
the ear. We have pointed out that this phenomenon is always to be heard 
most distinctly when the patient whispers, because it is then uninterfered 
with by the noise of the laryngeal notes. There is another reason why 
it should then be most audible. Since articulate sounds are produced in 
the mouth, it is obvious that, in order to reach the bronchial tubes they 
must pass the portals of the larynx. But in loud speaking these portals 
are closed, and must hence materially obstruct the transmission of such 
sounds; in whispering, on the other hand, they are to a greater or less 
degree patent, and the obstacle to their transmission is necessarily propor- 
tionately diminished. Pectoriloquy and bronchophony are not necessarily 
concurrent phenomena. Nevertheless, it is certain that pectoriloquy, like 
the other, is often detected both over consolidated lung-tissue and over 
cavities. We believe that it is most frequently and most distinctly audible 
over cavities which communicate freely with bronchial tubes. 

JEgophony is a modification of bronchophony, and gradually passes into 
it. It is generally compared, as it name implies, w r ith the bleating of a 
goat, or with the squeaking voice adopted by the exhibitors of ' Punch 
and Judy.' These comparisons are by no means inapt. The voice trans- 
mitted along the stethoscope differs materially in quality from the voice as 
it emanates from the patient's mouth ; it is, even if musical and full- toned 
as uttered, tremulous, bleating, and high-pitched as it reaches the auscul- 
tatory ear. Some degree of this quality of sound may occasionally be 
recognized, even in health, over the lower part of the chest behind. But 
it is only heard in perfection in the neighborhood of the lower angle of 
the scapula in cases of moderate pleuritic effusion ; and, indeed, when well 
marked, maybe regarded as pathognomonic of this condition. It is obvious 
that the peculiar bleating high-pitched character is due, as Dr. Stone has 
pointed out, to imperfect transmission of the voice, to the fact that its 
graver tones are lost or greatly enfeebled in transmission, while the higher 
tones and the harmonics of the graver tones are comparatively unaffected. 
In support of this view may be mentioned the fact that the regophonic 
sound, though apparently clearer, is often distinctly feebler than the nor- 
mal voice-resonance to be heard over the healthy lung. Sound, as is well 
known, is readily transmitted through either gases, fluids, or solids, but it 
does not so readily pass from one of these media to the others ; and it 
seems obvious, therefore, that the sounds produced within or carried into 
the bronchial tubes should experience some degree of filtration (so to 
speak) in passing from the tubes to the solid lung-tissue, from this to fluid, 
from this again to the thoracic parietes, and thence through the stethoscope 
to the ear. High notes are more penetrating than those of graver tone, 
and hence would be less likely to suffer in their passage. 

In association with pectoriloquy, bronchophony, or oegophony, there can 
generally be detected a distinct whiff of tubular quality, either accompany- 
ing or following the articulate or vocal sounds. In bronchophony and 
aegophony this is perceptible almost exclusively at the end of syllables, 
and chiefly at the end of those terminating with the explosive consonants 



352 



DISEASES OF THE RESPIRATORY ORGANS. 



£>, p, d, t, k, and hard ^7, an 1 is obviously due to the non-vocal rush of air 
through the open glottis, which, as a rule, follows on the utterance of these 
sounds. In whispered pectoriloquy, a similar whiff not only succeeds each 
syllable, but accompanies it during the whole period of its enunciation. 
These are merely tubular expiratory phenomena, due to the same cause as 
determines the ordinary tubular expiratory sound, and have no special 
significance. It should be added that, under similar circumstances, a 
like whiff or blowing sound follows each sonorous expiratory shock of 
cough. 

iv. Crepitation. Bales. — When mucus, serum, blood, or other fluids 
are contained in the air-tubes, the passage of air through them is attended 
with a variety of sounds to which the above and other names have been 
given. These are for the most part due to the passage of air in the form 
of bubbles of various sizes, and to the rupture of these bubbles at the sur- 
face of the fluid through which they pass, or to the separation of sticky 
surfaces. The size of the bubbles necessarily has a relation to the size of 
the tubes or cavities in which they occur. Thus if they be foumed in the 
air-cells or bronchial passages they must be excessively minute ; if in the 
trachea or larger bronchi they are generally of considerable size. The 
sounds to which they give rise depend partly upon their size, partly upon their 
number, partly upon the dimensions of the channel or cavity within which 
they are contained, and partly on the presence; or absence of consolidation in 
the lung-tissue around. Fine crepitation {crepitant rale) is produced only 
in the air-cells and bronchial passages, and may be regarded as almost char- 
acteristic of the first stage of pneumonia. [A rale indistinguishable from 
the crepitant rale is, however, occasionally heard in oedema of the lungs.] 
It is apparently due to the rupture of innumerable small bubbles, which 
individually are almost inappreciable, but collectively constitute a sound 
which has been aptly likened to that produced by rubbing the hair between 
the finger and thumb. Crepitation {mucous rale). — In all forms of crepi- 
tation, except that just spoken of, the bubbles which burst at one time are 
comparatively few ; moreover they are individually distinguishable, and 
differ. to some extent from one another in sound. The collective sonorous 
result, therefore, is more or less coarse and irregular. In some cases two 
or three crackles or clicks only can be detected in the course of an inspi- 
ration or expiration. In other cases they are so numerous that the whole 
of inspiration and perhaps the whole of expiration are noisy with them. 
It would be impossible to describe all the minute varieties of crepitation 
which may be included under the name which we have here selected. It 
is sufficient to say that they are probably all due to the presence of fluid in 
medium-sized and large tubes, that the differences which are presented 
depend partly on the quantity of fluid present, partly on its quality, and 
partly on the force with which air is driven through it, and that when the 
larger crepitation approaches that of pneumonia in quality, it is often 
termed ' sub -crepitation' or ' sub -crepitant mucous rale.'' Gurgling — This 
term fairly well explains itself, but is at the same time difficult to define. 
It implies partly large crepitation, such as may be heard in the trachea, 
partly the sounds which result from the mere agitation of fluid r falling, 
splashing, churning, and the like. It occurs in large tubes and cavities. 
Metallic Crepitation.— This term may be applied to large crepitation in 
which the bursting of the bubbles is attended with a distinct musical twang 
or metallic resonance. It is developed either in cavities or in large tubes. 
We have pointed out that cavernous or metallic respiration is never met 



AUSCULTATION. 



353 



with in undilated bronchial tubes ; the sharp, short sound, however, of a 
bursting bubble develops an audible resonance under conditions which 
would fail to affect similarly the prolonged and comparatively feeble respi- 
ratory murmur. 

v. Rhonchus This word is often used synonymously with rale, and 

both are often applied to all varieties of unnatural sounds caused by the 
presence of fluid in the bronchial tubes, or by diminution of their diameter. 
Rale, however, strictly means rattling or crepitation, which is essentially 
an unmusical sound ; whereas rhonchus signifies snoring, a sound always 
to some extent musical, and may conveniently be made to embrace all 
abnormal musical sounds which are occasioned in the bronchial tubes. 
Such sounds have sometimes a deep tone, almost exactly like an ordinary 
snore, or the cooing of a dove ; sometimes, on the other hand, they are 
high-pitched and of a whistling or hissing character. The deeper notes are 
usually termed ' sonorous,' the acuter notes 1 sibilant.' The former, like the 
voice itself, may produce distinct fremitus in the thoracic parietes, and 
both may be distinctly audible, not only to the patient himself, but to the 
mere bystander. The cause of rhonchus is, not the bursting of bubbles or the 
passage of air through fluid, but the passage of air through a tube narrowed 
at some point either by thickening of its parietes or by the adhesion of a 
plug of tenacious mucus. The almost complete closure of the tube, like 
the corresponding closure of the glottis in intonation, compels the passage 
of the air in a series of successive puffs, which soon become rhythmical, 
and hence a musical note results. The pitch of the musical note depends 
on various complex conditions, the exact influence of each one of which 
it would be difficult to estimate, but is determined in a very considerable 
degree by the size of the bronchial tube within which it is developed. 
Thus, as a general rule, hissing and whistling sounds or sibilant rhonchi 
arise in the smaller tubes, and grave tones or sonorous rhonchi are the 
product of the larger ones. 

vi. Splashing In large cavities containing air and limpid fluid, espe- 
cially therefore in cases of effusion into the pleura, associated with pneu- 
mothorax, a distinct splashing sound may often be caused by the process 
termed 1 succussion ;' in other words, by giving the patient a smart shake. 
This sound is often audible to the patient himself as well as toother atten 
tive listeners standing by. It may, of course, be more readily recognized 
by auscultation. 

vii. Amphoric babble. — In cases of hydro-pneumothorax may also be 
very rarely recognized a sound to which the name ' amphoric bubble' may 
perhaps be given. Our attention was first directed to it by Dr. T. A. 
Barker. On applying the stethoscope to the back in the interscapular 
region while the patient was sitting erect, and then making him gradually 
bend his trunk forwards, a sound, exactly like that which occurs during 
the decanting of wine, was distinctly audible. It was single only, but 
could be elicited as frequently as the patient was made to bend his body 
forwards to a certain angle. It was obviously due to the facts — that the 
partially-collapsed lung hung down from the apex of the pleural cavity so 
as to form an incomplete septum between its anterior and posterior parts ; 
that the lower margin of the lung dipped into the pleural fluid, thus render- 
ing the airchamber behind the lung and that in front of it discontinuous ; 
and that consequently, with change of posture, the level of the fluid tended 
to rise in one cavity and sink in the other, until the sudden passage of air 
from the one to the other was permitted under the septum. 

23 



354 



DISEASES OF THE RESPIRATORY ORGANS. 



viii. Friction-sounds are caused by the attrition of opposed pleural sur- 
faces. They never occur in the healthy pleura, and it is essential to their 
production that the surfaces be roughened by inflammatory or other deposit- 
Further, as a rule, they have very little intensity, and are scarcely if at all 
audible beyond the spot at which they are developed. Friction-sounds 
present many varieties of character. In some cases there is a uniform to- 
and-fro murmur accompanying inspiration and expiration, and having a 
close resemblance to the sound produced by rubbing two surfaces of paper 
together. In some cases the sound differs little if at all from some forms 
of intra- pulmonary crepitation : there may be a continuous crackling attend- 
ing one or both respiratory movements, or merely a few isolated clicks or 
crepitations. In a large number of cases the sounds, whether they be 
fine or coarse, occur in a series of irregular jerks. The jerks, indeed, may 
exist without the presence of actual friction sounds, in which circum- 
stances the respirations become (over limited area?) 'jerky,' or, as they are 
commonly called, ' wavy.' Friction-sounds have received various names, 
such as grazing, rubbing, creaking, and the like, which to some extent ex- 
press their quality. They have also been described as 1 superficial' in 
character. It need scarcely be remarked, however, that this epithet can 
have no other meaning, as applied to sounds, than that they are loud or 
distinct. Its use is altogether objectionable, as tending to cause confusion 
between the facts which we observe and the inferences we deduce from 
them. In cases of pleural friction, the rubbing of the opposed surfaces 
may produce a tremor in the thoracic walls, readily detectable by the hand. 
It may be observed that loudness or roughness of friction sound by no 
means necessarily implies either roughness, hardness, or abundance of 
lymph. The loudest and coarsest sounds are occasionally produced by the 
thinnest, softest, and most recent films. 



E. Detection of Cavities, Consolidated Lung, and Pleural Effusion. 

Before leaving the subjects of auscultation and percussion it may be 
convenient to recapitulate the phenomena which attend and indicate the 
presence of cavities, of consolidated lung, and of pleural effusion. 

1. The detection of cavities is often very important ; and in a large 
number of cases, no doubt, by considering the patient's history, the results 
of periodical examinations of his chest, and the presence or absence of 
certain special acoustic phenomena, Ave may arrive at a fairly correct con- 
clusion. But the acoustic phenomena which by their presence prove the 
existence of a cavity are, as Skoda asserts, very few indeed. Dulness, 
bruit de pot fele, normal resonance, tympanitic resonance, high-pitched 
resonance may each be present. Feebleness, with indeterminate character 
of the respiratory sounds, tubular sounds, gurgling, may also be present in 
its turn. There is probably always more or less marked bronchophony 
and pectoriloquy. Pectoriloquy, indeed, is more distinct, as a rule, over 
cavities than over merely consolidated lung. The only sounds, however, 
which positively indicate the presence of a cavity, are : first, the musical 
or metallic ring or resonance which sometimes accompanies the respiratory 
sounds, the voice, the movements of fluid in the cavity, and the percussion 
stroke upon its walls ; second, the splashing sound caused by succussion ; 
and, third, the production of the amphoric bubble to which we have ad- 
verted. But these sounds may all be absent from cavities even of large 
size. 



LARYNGITIS AND TRACHEITIS. 



355 



[More than twenty years ago, Dr. Austin Flint pointed out certain 
differential characters, consisting principally in variations of pitch and 
quality between tubular and cavernous respiration, attention to which will 
often enable the auscultator to recognize the presence of a cavity, which 
might otherwise escape detection. The principal points of distinction are 
as follows : In bronchial respiration, the expiratory sound is of higher 
pitch, and usually more intense and prolonged than the inspiratory, while 
both sounds are distinctly tubular in quality. In cavernous respiration 
on the other hand, the expiratory sound is much lower in pitch than the 
inspiratory, both sounds being non-vesicular in quality.] 

2. The conditions which collectively indicate consolidation are sense of 
resistance, impaired or annulled resonance, increase of vocal fremitus, 
tubular breathing, or correspondingly modified conditions of rhonchus or 
crepitation, brochophony, and pectoriloquy. These conditions are, how- 
ever, by no means necessarily all present in every case. 

3. The indications of pleural effusion are dulness on percussion, with 
variation of the limits of dulness and resonance in accordance with varia- 
tion of posture, tubular breathing, or more frequently extreme feebleness or 
absence of respiratory sound, impairment or suppresion of vocal fremitus, 
and segophony. To which may be added, dilatation of the affected side 
and intercostal spaces, with sometimes obvious fluctuation ; and displace- 
ment of the diaphragm downwards and of the mediastinum to the opposite 
side. But, again, many of these phenomena are often absent from other- 
wise well-marked cases of effusion. 



II. LARYNGITIS AND TRACHEITIS. 

Causation The chief cause of laryngeal and tracheal inflammation is 

exposure to cold or wet, or both. It is then sometimes the primary 
affection, but is often a mere extension of ordinary catarrh or of acute 
bronchitis. It may be due, however, to many other causes : to the local 
operation of irritating gases, fluids, or solid particles, among which may 
be enumerated boiling water, vomited matters, and puriform secretions 
furnished by the lung itself ; to the presence of certain morbid conditions 
or diseases, such as variola, measles, scarlet fever, diphtheria, erysipelas, 
and we may add syphilis and tuberculosis ; to the extension of inflamma- 
tion from subjacent tissues; and even, as regards the larynx, to sustained 
or violent exertion, as occurs in clergymen and other public speakers, and 
in those who strain themselves in coughing or shouting. It may be deter- 
mined also by local violence. There are, further, many conditions which 
predispose to it; among the most important of which is the fact of having 
suffered from a previous attack, and the presence of Bright's disease. 

Morbid anatomy — The local changes which attend and indicate laryn- 
gitis are those of inflammation of mucous membrane generally, with 
modifications due to peculiarities of arrangement and structure which the 
laryngeal tissues present. The mucous membrane and subjacent parts are 
congested and oedematous; and the epithelial surface, at first (as in ordi- 
nary nasal catarrh) preternaturally dry, soon secretes, though not in large 
quantities, a glairy, transparent mucus, which subsequently becomes thick 
and muco-purulent. In ordinary mild cases the tumefaction and redden- 
ing are slight yet pretty uniformly diffused — the vocal cords being prob- 



356 



DISEASES OF THE RESPIRATORY ORGANS. 



ably more or less injected and swollen, and studded with flakes of adherent 
mucus. In more severe cases the submucous tissue may be largely in- 
filtrated and oedematous ; and hence the affected regions often assume a 
translucent, almost jelly-like, aspect, though still presenting a congested 
surface. Such swelling, or oedema, may affect mainly the epiglottis, 
aryteno-epiglottidean folds, false vocal cords, or some other limited tract, 
or may be general. It must be borne in mind, however, that those parts 
the tissues of which are closest in texture suffer least in this respect, and 
that hence the free edge of the epiglottis and the true cords for the most 
part escape. In most cases the secretion from the mucous membrane 
presents simply the ordinary characters of mucus or muco-pus. But in 
some (even in the absence of diphtheria) an adherent false membrane 
forms upon the surface. This sometimes follows the attempt to swallow 
boiling water. Ulceration is an unusual sequel of ordinary inflammation. 
It occurs most commonly, perhaps, in the course of phthisis and constitu- 
tional syphilis, even when no specific lesions are present. 

Ulceration in phthisis may be the result of simple excoriation. It then 
begins with round or oval shallow, saucer -like depressions, of an ashy 
color and with congested margins. Its most important, if not commonest, 
seat is the point of the processus vocal is. Ulcers in this situation incline 
to extend deeply, to expose more or less of the arytenoid cartilages, and 
to lead to their partial or total destruction by caries or necrosis. There is 
a great tendency, indeed, both in phthisis and in syphilis, for ulceration to 
involve the cartilages — arytenoid, cricoid, and thyroid — and to cause their 
erosion or necrosial destruction. But in some cases the cartilaginous 
affection takes its origin in inflammation of the perichondrium. For the 
most part the necrosed cartilages have undergone more or less complete 
ossification. The forms of laryngitis last referred to may be regarded as 
essentially of a chronic nature; but simple laryngitis also may become 
chronic. The anatomical characters of this variety differ but little from 
those of the acute affection. The chief distinctions are that, in the former 
case, the inflammatory redness is less intense, and the thickened tissues 
are more opaque and apparently more solid : they lose their peculiar oede- 
matous character. When' laryngitis becomes chronic the follicles of the 
affected surface often undergo hypertrophy. To such cases the name of 
'•glandular laryngitis'' has been given. 

The changes which take place in tracheitis are essentially identical with 
those which characterize laryngitis. The surface, which is at first drier 
than natural, soon secretes an over-abundance of modified mucus, and oc- 
casionally, like that of the larynx, gets covered with an adherent pellicle. 
The mucous membrane itself, and the subjacent tissues, become congested 
and infiltrated ; and not unfrequently, especially in syphilis and phthisis, 
ulceration takes places. The ulcers are mostly, in the first instance, mere 
excoriations, which tend gradually to increase in area and thus to coa- 
lesce, and in depth so as gradually to expose the cartilages. The latter 
may thus get eroded or necrosed, and even detached and expectorated. 
Abscesses may form in the walls of the trachea or external to them, and 
communications may be established between its tube and that of the oeso- 
phagus. The healing of ulcers whether in the larynx or trachea may 
produce serious cicatricial contraction. 

Symptoms and progress. — 1. Acute laryngitis is mainly dangerous from 
the fact that it is liable to cause serious obstruction to the passage of air 
through the rima glottidis, and hence death from suffocation. The inflam- 



LARYNGITIS AND TRACHEITIS. 



357 



mation is for the most part of little intensity, and gives rise to compara- 
tively slight constitutional disturbance. There is usually during the earlier 
period of the affection more or less elevation of temperature, acceleration 
and hardness of pulse, flushing of the face, furring of the tongue, thirst, 
and loss of appetite. But in favorable cases these symptoms soon subside, 
and in unfavorable cases get replaced by those of asphyxia. 

The special symptoms of laryngitis are often preceded by those of ordi- 
nary catarrh, and especially by those of catarrhal affection of the fauces, 
which, in many respects, they resemble. The patient complains of dry- 
ness or roughness, soreness, itching, pricking, or aching, or it may be of 
several or all of these sensations, which he refers to the back of the throat 
and to the region of the thyroid cartilage. There is generally also some 
tenderness to touch, and there may be absolute pain when the parts are 
roughly handled. The sense of soreness is aggravated by the act of 
swallowing, especially if solid matters be taken ; and there is commonly 
also a good deal of aching thus caused besides soreness. The dryness and 
irritability of the throat compel the patient nevertheless to make constant 
efforts at deglutition, and at clearing the throat, and excite more or less 
frequent spasmodic attacks of cough. The voice gets altered in quality, 
and respiration somewhat impeded. Examination with the laryngoscope 
reveals congestion, with more or less thickening, of the mucous membrane ; 
and if the parts above the vocal cords be much affected they may entirely 
conceal the rima glottidis and its surroundings from view. 

Certain of the symptoms here enumerated require to be considered a 
little more in detail. Some degree of interference with the freedom of 
respiration is probably always experienced, and this under the influence of 
excitement or sudden spasm, may readily amount to manifest dyspnoea ; 
expiration is a little prolonged, and tends perhaps to be wheezy. But very 
often matters become much more serious ; both inspiration and expiration 
(the former more especially), even when the patient is at rest, get harsh 
or whistling, noisy and prolonged, and he suffers from continuous difficulty 
of breathing. In cases of still greater severity all the symptoms of as- 
phyxia become developed ; the patient sits up in bed gasping for breath, 
which is still harsh, wheezy, or whistling ; with his head thrown back, his 
mouth open, his nostrils dilated, his respiratory muscles acting with spas- 
modic force; anxious, restless, throwing his arms about, or clutching at 
any support which may be near ; with eyes prominent and staring, face 
livid and ghastly, skin bathed in sweat, and pulse rapid, small, failing, and 
perhaps irregular. Under these circumstances death may occur suddenly 
from complete obstruction of the rima glottidis. But more commonly the 
patient begins to ramble, and presently passes into a condition of insensi- 
bility, upon which death gradually supervenes. 

The voice is almost invariably altered in quality ; it becomes hoarse, 
uncertain, or reduced to a whisper. In the beginning it is in general 
merely hoarse ; it is somewhat rougher than natural, and at the same time 
deeper toned — phenomena which depend, either on the adhesion of mucus 
to the edges of the vocal cords, or on some modification in their thickness, 
elasticity or tension. This hoarseness is sometimes apparent only on rising 
in the morning, and disappears during the day ; it is apt, however, to be 
brought on again, and to be converted into actual aphonia, by unwonted 
use of the voice. At a later period of the disease, when the tissues above 
the vocal cords are highly osdematous, or the cords are much thickened 
and scarcely movable, complete aphonia is usually present. 



358 



DISEASES OF THE RESPIRATORY ORGANS. 



The cough varies in severity ; sometimes it is incessant, or comes on in 
uncontrollable paroxysms. But it is generally attended with so much 
pain in the larynx that the patient endeavors (probably in vain) to sup- 
press it. It is always at first, like the voice, hoarse and loud; and in 
many cases, especially in children, and where there is manifest dyspnoea, 
its inspiratory element is long, loud, and whistling, and the expiratory 
effort is attended with a remarkably harsh, sonorous, metallic clang. Later 
on, the cough, like the voice, becomes ineffective, wheezy, or aphonic. 

Acute laryngitis is very apt to be attended or followed by bronchitis, or 
(especially in children) by collapse and lobular pneumonia — complications 
which aggravate the patient's symptoms and add very materially to his 
danger. It is sometimes as rapidly fatal as almost any disease with which 
we are acquainted ; but in a large proportion of cases is so mild in its 
symptoms that but little attention is paid to it; yet it is always attended 
with risk, and should be carefully treated. 

The frequency of the occurrence of laryngitis in a mild form is evidenced 
by the frequency with which persons, after exposure to cold, suffer from 
soreness referable to the larynx, and hoarseness or loss of voice. This 
affection generally lasts for three or four days, subsides with increase of 
laryngeal secretion, and leaves no ill consequences behind. Dr. Cheyne 
asserts that hoarseness is an uncommon phenomenon in the catarrhal affec- 
tions of young children, and that its occurrence should make us dread the 
supervention of croup. Our own belief, on the other hand, is that hoarse- 
ness is not uncommon in children, and that it has no more serious import 
in them than in adults. The phenomena, however, of slight laryngitis in 
children under two or three years of age, and even in those who are a 
little older, are often so remarkable that they are confounded with those 
of spasmodic croup or laryngismus stridulus. The child, after having 
suffered from slight catarrhal symptoms, or sometimes in the midst of 
apparently good health, wakes suddenly during the night in an agony of 
dyspnoea. He starts up in bed with a look of extreme anxiety and terror, 
gasps for breath, inspires laboriously with a hissing or whistling sound, 
and coughs at intervals with a series of harsh, loud, metallic, expiratory 
shocks ; his voice is hoarse or reduced to a whisper. After the symptoms 
have lasted half an hour or more, during which time the patient has been 
enduring all the horrors of impending suffocation, they subside, the skin 
gets moist, and he falls into a comfortable sleep. The next day he proba- 
bly appears to be pretty well, although there may still be some hoarseness 
of voice and the cough may still have a croupy character. It is not un- 
common for such attacks to occur two or three nights or more in succes- 
sion. There can be no doubt that they are mainly spasmodic ; and there 
is some reason to suspect that they are often induced immediately by the 
entrance of saliva, or even of regurgitated food, during sleep, into the 
larynx. They are. seldom fatal. Neither of the above forms of laryn- 
gitis, however, differs essentially from the rarer cases in which the symp- 
toms early assume an aggravated character, and in which the patients die, 
suffocated at periods varying from a few hours to two, three, or four days. 

2. Chronic laryngitis Under the head of chronic laryngitis may be 

included : first, simple laryngitis, which has assumed a chronic form ; 
second, aphonia clericorum ; and third, ulcerative processes connected 
especially with pulmonary tuberculosis and syphilis. In the first variety 
the symptoms differ but little from those of the acute affection, excepting 
in their comparative mildness. They are liable, however, to exacerba- 



LARYNGITIS AND TRACHEITIS. 



359 



tions, and rapid oedema of the submucous tissue may at any time ensue. 
Dr. Mackenzie states that in this form of chronic laryngitis the aryteno- 
epiglottidean folds are comparatively rarely congested and swollen, but 
that it is chiefly the false vocal cords, capitula Santorini, and epiglottis 
which suffer. 

Aphonia clericorum may originate in catarrh, like other forms of laryn- 
gitis, or may be the result of simple over-exertion. It soon, however, and 
mainly in consequence of the persistent use of the voice, becomes a chronic 
affection. Its symptoms are like those of ordinary chronic laryngitis, but 
on the whole are more mild. The patient, indeed, often suffers from little 
except a sense of dryness in the throat, persistent hoarseness, and a ten- 
dency to hawk and clear the throat. Laryngoscopically, the appearances 
are those of chronic laryngitis. It is stated, however, that in this case 
there is a special tendency to hypertrophy of the laryngeal glands, and that 
their enlarged orifices may often be distinctly recognized. 

The laryngeal affection which so commonly attends pulmonary phthisis 
creeps on insidiously, and is sometimes far advanced before the pulmonary 
disease has made very manifest progress. It differs from the varieties of 
chronic laryngitis above considered in its progressive aggravation and its 
incurability. At the beginning it presents no special symptoms; but as 
the disease goes on complete aphonia, dyspnoea which may be exceedingly 
severe, and pain and difficulty in swallowing, become established ; indeed, 
in many cases swallowing becomes almost impossible, on account of the 
passage of food through the rima glottidis when the act is attempted. On 
laryngoscopic examination, the soft parts are seen to be more or less 
thickened, sometimes congested, sometimes pale, and for the most part 
opaque ; and Dr. Mackenzie draws attention to the fact that the aryteno- 
epiglottidean folds usually look like, 'two large, solid, pale, pyriform 
tumors, the large ends being against each other in the middle line, and 
the small ones directed upwards and outwards.' The presence of ulcers 
may sometimes be recognized. Syphilitic affections of the larynx are not 
wholly specific. But, whether specific or not, the symptoms to which they 
give rise are those of progressive chronic laryngitis. In the later stages 
of constitutional syphilis extensive ulceration of the larynx is not uncom- 
mon, and in this case, as well as in so-called ' laryngeal phthisis,' there is 
a great tendency for caries or necrosis of the various cartilages to take 
place. Here, however, the epiglottis is most prone to suffer. Such com- 
plications, no matter what their cause, always largely diminish the ultimate 
prospect of even partial recovery, and bring in their train special symp- 
toms in addition to those of simple laryngitis. Among these may be men- 
tioned: infiltration and oedema of the tissues of the neck superficial to the 
laryngeal cartilages ; fetid breath and purulent discharge ; the occasional 
separation of portions of cartilage or bone, which may either be expecto- 
rated or cause sudden death by obstructing the laryngeal orifice ; the form- 
ation of abscesses or sinuses which may open in various positions ; the 
perforation of arteries, with profuse and fatal hemorrhage ; and occasion- 
ally, as a sequela of the separation of sequestra and cicatrization, perma- 
nent and serious contraction of the glottis or other parts of the laryngeal 
canal. 

3. The symptoms due to tracheitis are scarcely distinguishable from 
those of inflammation of the larynx. It may be observed, however, that 
in inflammation limited to the trachea there is not necessarily any pain in 
the pharyngeal stage of deglutition, or any affection of the musical quality 



360 



DISEASES OF THE RESPIRATORY ORGANS. 



of the voice, and that, while the danger of suffocation is less, the benefit to 
be expected from tracheotomy is also less. Further, some tenderness in 
the course of the trachea may be expected, some pain in the same situa- 
tion on coughing, and some tenderness or soreness in the passage of food 
along the oesophagus. 

Treatment The treatment of laryngitis may be divided into the con- 
stitutional or general, and the local, of which the latter is by far the most 
important. The local treatment to the exterior of the larynx comprises 
leeches (which should be applied over the upper part of the sternum), 
blisters and other counter-irritants (which are also best applied in the same 
region), and poultices or hot fomentations over the larynx itself. For 
internal local treatment may be employed : the inhalation of steam, simple, 
or medicated with volatile aromatic or sedative substances such as turpen- 
tine, camphor, benzoin, creasote, or conium; the inhalation of atomized 
fluids such as solution of sulphate of zinc or copper, acetate of lead, alum, 
nitrate of silver, perchloride of iron, or tannin ; the application, by means 
of a sponge or brush, of strong solution of nitrate of silver (5j, ad ^j), 
tincture of perchloride of iron (3j, 3 lb a( l ^j), or any of the other articles 
just enumerated ; the insufflation of finely-powdered astringents or seda- 
tives; and scarification of the congested or oedematous tissues. In order 
that the internal local treatment may be effectual, it is important that (ex- 
cepting in the case of simple inhalation) the remedies should be applied by 
means of special apparatus under the guidance of the laryngoscope. The 
application of ice or cold compresses to the exterior of the larynx, and the 
sucking of ice, are measures which *may often be adopted with advantage. 
As to general treatment, we must be governed mainly by the constitutional 
condition of the patient and by the character of his attack. In acute cases, 
ipecacuanha, tartar emetic, and other nauseating remedies have been largely 
advocated ; opium, as in most inflammatory affections, especially such as 
are attended with pain or distress, is often of extreme value. AVarm 
baths, and the retention of the patient in an equable, warm, moist atmos- 
phere, are generally of use in the treatment of acute cases ; in the treat- 
ment of chronic cases, iron and other tonics, cod-liver oil, change of air, 
and, if need be, iodide of potassium, or mercurial salts. 

' In the laryngitis which so often attends an ordinary catarrh it is ad- 
visable to keep the patient in a warm atmosphere, at any rate free from ex- 
posure to draughts, to apply hot fomentations or mustard plasters externally, 
to order him to gargle his throat frequently with warm milk or with 
slightly astringent solutions, or to relieve his faucial discomfort by the 
use -of gelatinous or oleaginous substances — among which may be included 
common calvesfoot jelly and black currant jelly — or to inhale steam. Dia- 
phoresis may be encouraged, and expectorant medicines may be admin- 
istered. Opium is of great value in relieving the patient's discomfort. 
When the case is severe from the beginning, or when it begins to assume 
a serious aspect, our local treatment must be more active : leeching exter- 
nally, and scarification within, become then of essential importance. 
Sometimes in such cases swabbing the throat with strong solution of nitrate 
of silver, perchloride of iron, or alum, is followed by the best results. In 
the stridulous laryngitis of young children the danger is mainly momen- 
tary (so to speak), and due to spasm ; and treatment, therefore, if it is to 
be efficacious, must be prompt. Generally it is advisable to place the 
patient in a hot bath, and to apply a sponge wrung out in hot water over 
the larynx. It is usually customary to administer an emetic dose of ipecacu- 



BRONCHITIS. 



361 



anha or sulphate of zinc. It may, however, be questioned whether the 
inhalation of chloroform is not more likely to be beneficial than the use of 
an emetic. In the chronic form of laryngitis, local bleeding and scarifica- 
tion are rarely necessary except to relieve exacerbations ; but blisters and 
other counter-irritants externally, and the systematic employment of medi- 
cated applications to the interior of the larynx, are then specially indicated. 
In the so-called ' aphonia clericorum' prolonged rest from the use of the 
voice should especially be enjoined. In all cases, whether they be acute 
or chronic, specific or non-specific, it must be borne in mind that we may 
be called upon at any moment to save life by the performance of trache- 
otomy. The need for its performance must generally be determined at 
the moment. It is difficult to lay down precise rules for the guidance of 
the judgment of the medical attendant in such cases. It is probably suffi- 
cient to say that no one ought to be permitted to die of uncomplicated 
laryngeal obstruction without having that chance of recovery given him 
which tracheotomy affords ; that it is unwise to delay the operation until 
the patient is moribund ; that it is better to perform it too early or even 
needlessly than too late ; and, lastly, that it should not necessarily be dis- 
carded even if the patient appears to be just dead. 



III. BRONCHITIS. 

Causation Inflammation of the bronchial tubes is dependent chiefly on , 

exposure to cold. But it also arises, like laryngitis, from the inhalation 
of irritant matters ; as a complication or sequela of various febrile disorders, 
such as influenza, hooping-cough, measles, and typhoid fever ; and in con- 
nection with various idiopathic affections, more especially heart and kid- 
ney diseases. It may also be developed under the influence of pulmonary 
tuberculosis and carcinoma, and probably, too, in connection with syphilis 
and gout. Its prevalence depends largely upon temperature and season, 
and hence it is chiefly fatal in autumn and winter ; it is favored by such, 
occupations as expose persons to the influence of irritant or other noxious 
matters, and such as necessitate frequent and sudden exposure to variations 
of temperature ; it affects persons of all ages and of either sex, but it has 
a marked preference for such as have had previous attacks, and is espe- 
cially fatal in early infancy and in old age. 

Morbid anatomy — Inflammation of the bronchial tubes, like inflamma- 
tion affecting other mucous membranes, is attended with changes in their 
epithelial covering and glandular secretions, and in the subjacent tissues. 

The discharge is, in the first instance, diminished in quantity, but soon 
becomes more abundant than in health, thin, transparent, and either 
watery or viscid, and subsequently acquires more or less opacity and thick- 
ness, and a yellowish or greenish tint. Sometimes it remains watery, 
sometimes assumes the characters of pus, and not unfrequently, if the in- 
flammation be intense or the congestion great, presents streaks and spots 
of blood. Under the microscope the viscid transparent secretion presents 
abundance of shed ciliated epithelial and other cells ; and the acquisition of 
opacity is connected with the more or less complete replacement of these 
by cells of embryonic character, fatty or granule cells and pus corpuscles. 
In some rare cases groups of bronchial tubes are found occupied by lami- 



362 



DISEASES OF THE RESPIRATORY ORGANS. 



nated fibrinous casts, which on separation present a branching or tree-like 
aspect. 

The mucous membrane becomes congested, sometimes intensely con- 
gested, and the seat of minute extravasations of blood; at the same time 
it undergoes more or less infiltration and thickening, and may even acquire 
a granular or villous aspect, and a soft or pulpy consistence. It is im- 
portant, however, to know that, in a large number of cases, especially 
chronic cases, the congestion disappears wholly after death, and the mucous 
membrane seems scarcely changed either in thickness or in texture. 

The inflammatory process may be limited to the surface of the mucous 
membrane; but it often pervades the submucous tissue; and in some cases 
involves the whole thickness of the bronchial walls, leading also to more 
or less obvious infiltration and induration of the connective tissue which 
surrounds them. In the last case the muscular fibres may either, if merely 
irritated, be stimulated to unwonted action, or undergo atrophy or degene- 
ration, and lose their contractile properties. In most cases of bronchitis 
the mucous membrane remains whole; but occasionally ulceration takes 
place. This is more common in phthisis than in the uncomplicated dis- 
ease, and usually commences, as does tracheal or laryngeal ulceration, in 
simple excoriation. The excoriations, at first small and round or oval, 
gradually enlarge and coalesce, and at the same time tend to increase in 
depth. Thus the walls may undergo gradual removal (the cartilages dis- 
appearing either by caries or necrosis), the surrounding lung-tissue share 
to a greater or less extent in the destructive processes, and the tubes be 
converted into irregular channels bounded by diseased lung-tissue. In 
some cases gangrene occurs. Ulcerative destruction occasionally takes 
place from without, as when a pulmonary, glandular, or other abscess opens 
into an adjoining tube. It is thus that abscesses about the roots of the 
lungs discharge themselves into the bronchi, and that calcareous matter 
from diseased bronchial glands finds its way into these or smaller tubes. 

Bronchitis is limited, in a large proportion of cases, to the tubes of large 
and medium size; but sometimes affects mainly or entirely the minuter 
tubes. In the latter case, not only is the affection marked by greater in- 
tensity of symptoms and aggravated danger to life, but the local patholo- 
gical changes assume a more serious character ; the thickening of the mucous 
membrane encroaches more seriously on the channels of the affected tubes, 
and their secretions tend to accumulate in them and to block them up 
completely. Hence post mortem we not unfrequently find the smaller 
tubes distended with pus or mucus, void of air, and quite impermeable. 

The indirect influence of bronchitis over the structural condition of the 
bronchial tubes and of the proper tissues of the lungs is very remarkable. 
As regards the tubes, we have already pointed out that, by extension of 
ulceration, they may be converted into irregular channels; this change, it 
need scarcely be said, may be seen in its greatest perfection in connection 
with the capillary or terminal tubules. But, independently of ulceration, 
the tubes, and especially the smaller ones, may undergo considerable dila- 
tation from the combined effects of simple accumulation of contents and 
inflammatory weakening of their walls. In acute bronchitis, attended 
with much secretion, the lung-tissue often becomes preternaturally dis- 
tended with air, and retains the accumulated air even after death; 1 1 1 \s 
condition is sometimes incorrectly termed emphysema; but it not unfre- 
quently proceeds to actual emphysema, in which the vesicular structure is 
more or less seriously disorganized. Besides over-distension, the exactly 



BRONCHITIS. 



363 



opposite condition of pulmonary collapse is often met with, sometimes alone, 
sometimes associated with over-distension of other parts ; collapse is inti- 
mately related to another frequent complication of bronchitis, and indeed 
passes by insensible gradations into it ; we mean lobular pneumonia. All 
the secondary phenomena arising in the progress of bronchitis, which have 
here been enumerated — namely, dilatation and destruction of tubes, dila- 
tation and destruction of air-cells or emphysema, lobular collapse, and 
lobular pneumonia — form a more or less important part of chronic bron- 
chitis, and tend both to aggravate its symptoms and to perpetuate them. 
It will, nevertheless, be more convenient to defer their complete discus- 
sion. 

Symptoms and progress. — The symptoms of bronchitis comprise, in 
varying proportions, those of inflammatory fever, those of defective aeration 
of blood, and those directly referable to the condition of the bronchial tubes 
and lungs; to which may be added those arising from mechanical impedi- 
ment to the transmission of blood through these organs. 

The symptoms of inflammatory fever are always most pronounced at the 
commencement of acute attacks and of exacerbations of the chronic affec- 
tion, and often disappear wholly, to be replaced by other conditions, during 
the progress of the disease. The temperature, excepting in very severe 
cases, especially of capillary bronchitis, and in young children, rarely ex- 
ceeds 100° or 101°. In exceptional cases it may amount to 102°, 103°, 
or 104°. With elevation of temperature there may at first be chills or 
rigors, and dryness of skin. But perspirations, more or less profuse, are 
very apt to alternate with dryness, or to replace it. The pulse becomes 
accelerated, the respirations somewhat hurried, the tongue furred; the 
patient has thirst, loss of appetite, constipation, and scanty turbid urine ; 
he probably complains of headache and febrile pains in his limbs; and he 
is apt to be drowsy, though often wakeful at night. 

Diminished aeration of the blood tends to the reduction of temperature, 
to interference with the processes of nutrition, and to enfeeblement of the 
heart's action and of the pulse. . The temperature of bronchitis may hence 
be subnormal even in acute attacks. The pulse, moreover, is sometimes 
full and incompressible, owing either to increase of arterial tension second- 
ary to venous obstruction, or to poisoning of the nervous centres ; and in 
chronic cases it is often abnormally slow. The face, and especially the 
lips and cheeks, assume a pale or livid hue ; profuse perspirations break 
out ; and there is a tendency to impairment of the mental faculties, to 
delirium, and coma. 

The local symptoms are due to the processes going on in the bronchial 
tubes. They comprise cough, at first dry and irritable, later on freer and 
attended with expectoration ; difficulty of breathing, with increase in the 
number of respirations and in the efforts required of the patient ; compara 
tive prolongation of the acts of expiration ; and the various forms of rhon- 
chus and crepitation, which are caused by thickening of the bronchial 
mucous membrane, or secretion into the tubes. 

1. Acute bronchitis The symptoms of bronchitis vary considerably 

according to its severity and the conditions which cause or complicate it. 
In its mildest form it is a comparatively trivial affection. It then usually 
commences with ordinary catarrhal inflammation of the upper part of the 
respiratory tract, which gradually travels downwards, involving first the 
larynx, and then the bronchial tubes. It is attended with febrile disturb- 
ance, irritability of the bronchial mucous membrane, tickling or uneasy 



364 



DISEASES OF THE RESPIRATORY ORGANS. 



sensations in the throat, burning, soreness or rawness within the chest, and 
more or less frequent cough, the paroxysms of which cause considerable 
aggravation of the intra-thoracic discomfort. There is frequently, also, 
some tenderness over the manubrium, with tenderness and aching of the 
muscles of the upper part of the front of the chest. The cough is at first 
dry, but in a short time becomes loose and attended with the discharge of 
transparent glairy mucus. With the progress of the case the sputa get 
opaque and muco-purulent, then gradually cease, and health is restored at 
the end of a few days, or at most after the lapse of a week or two. 

In more severe cases, the symptoms are the same in kind, but aggra- 
vated. The febrile phenomena which usher in the attack are more intense, 
the cough and pain in the chest are more distressing, and there is more or 
less obvious dyspnoea. There may indeed, while the mucous membrane is 
simply swollen, and the cough is yet dry, be great apnceal distress and 
lividity of surface, and the patient may even at this stage die asphyxiated. 
More commonly, however, here as in the former case, the mucous surface 
ere long begins to discharge, and the cough to be attended with expecto- 
ration, which, except that it is probably much more profuse and apt to be 
streaked with blood, passes through the ordinary phases. During this 
period, also, death may take place from accumulation of fluid in the bron- 
chial tubes and consequent slow asphyxia ; or, without the actual super- 
vention of asphyxia, the patient may gradually pass into a typhoid state, 
with feeble, quick, irregular pulse, dry cough, copious sweats and delirium; 
or he may sink from a combination of these conditions. Occasionally death 
is sudden, owing to the sudden obstruction of some of the larger tubes. 

The most dangerous form of acute bronchitis is that which commonly 
goes by the name of ' capillary bronchitis.' It is that form in which the 
inflammation affects mainly, if not exclusively, the minuter bronchial 
tubes. It is most common in children, yet not infrequent in persons of 
more advanced age. The fever which ushers it in is generally pretty in- 
tense, the difficulty of breathing and lividity are considerable; the cough, 
however, may be much less troublesome than in other cases, and even 
during the stage of secretion may, owing to the difficulty of dislodging 
accumulations in the minuter tubes, remain inefficacious and dry. Further, 
there is generally comparatively little intrathoracic pain even in violent 
coughing. The tendency in capillary bronchitis is to speedy death from 
asphyxia and debility. 

The auscultatory phenomena of bronchitis comprise mainly sonorous and 
sibilant rhonchi, and crepitation of various sizes. Musical rhonchi are 
chiefly heard during the dry stage, crepitation during the later stages, but 
even then musical sounds are apt to be present to a greater or less extent. 
In capillary bronchitis the rhonchus is mostly sibilant, and the crepitation 
small. The sounds elicited by percussion differ little from those of health. 
If the lung-tissue be much distended with air, as it often is, the percussion 
sound may be somewhat more resonant than normal ; but obvious dulness 
is rarely produced, even if there be lobular collapse, unless the collapse be 
extensive, or unless pneumonia or other complications be present. 

2. Chronic bronchitis Bronchitis often assumes a chronic form, espe- 
cially among the laboring classes, and in middle or advanced life. It may 
become chronic, however, at all ages, and in persons of any grade of so- 
ciety. When a patient suffering from acute bronchitis continues to expose 
himself to the conditions which caused it, the inflammation is likely to be 
kept up ; and again, bronchitis is one of those affections which, when once 



BRONCHITIS. 



365 



they have been experienced and cured, tend to recur on the slightest pro- 
vocation. The ordinary history of a case of chronic bronchitis is to the 
effect that the patient, after exposure to weather, probably during the 
winter, has an attack of the disease, from which he recovers during the 
ensuing spring, remaining fairly well until the approach of the following 
winter ; that then a fresh attack is contracted, from which again recovery 
takes place ; that these attacks of winter cough then recur annually, grad- 
ually increasing in severity and duration, and being separated from one 
another by shorter and shorter intervals of comparatively good health; and 
that each successive interval becomes a period of increasing shortness of 
breath, until it merges in that of the bronchitic condition, which thus be- 
comes continuous, although still probably presenting winter exacerbations. 
Each bronchitic attack differs but little in its symptoms from an ordinary 
acute seizure, excepting perhaps that it is rarely attended with such mani- 
fest febrile disturbance, and that the expectoration is apt speedily to assume 
the muco-purulent condition and to continue of this character, and at the 
same time to become more or less abundant, until the approach of the 
long-delayed convalescence. 

The successive long-continued attacks generally lead gradually but surely 
to those structural pulmonary changes which have been already enumerated, 
and to those various remote lesions referable to long-continued congestion 
of the systemic venous system which follow equally on this disease and on 
cardiac affections ; the mucous membrane tends to secrete more abundantly 
than natural, even when the patient is otherwise apparently well ; emphy- 
sema, or dilatation of the tubes, or both of these conditions, gradually 
supervene ; the right side of the heart becomes dilated and hypertrophied ; 
and systemic venous congestion ensues, in which the liver and kidneys 
especially share. The symptoms due to these lesions are consequently 
added one after another to those of simple bronchitis ; the patient soon 
begins to suffer from persistent shortness of breath and bronchial accumu- 
lation, and sooner or later gets cyanotic or anasarcous and the subject, may 
be, of jaundice or albuminuria. 

The thorax of a patient who has suffered long from chronic bronchitis 
gradually assumes, in consequence partly of his persistent powerful inspi- 
ratory efforts, partly of emphysema, a rounded form — the well-known barrel 
shape which is so common in this affection. 

Cases of chronic bronchitis within certain limits, differ widely from one 
another in their severity, and in the symptoms with which they are attended. 
We may perhaps mention that in some the bronchial secretion is so scanty, 
other symptoms being well developed, that the affection has been termed 
' dry bronchitis that, in some the discharge is so profuse, that the name 
' bronchorrhozcC has been given to the malady; and that, in other cases, 
even where no gangrenous condition is present, the expectoration is dis- 
gustingly fetid — a condition which is said to be chiefly met with when 
there is dilatation of the bronchial tubes. The expectoration and the aus- 
cultatory, percussive, and tactile phenomena yielded by persons suffering 
from chronic bronchitis present no material differences from those presented 
by patients suffering from the acute disorder, and call, therefore, for no spe- 
cial description. Death, in which, sooner or later, the chronic disease so 
often terminates, is usually due either to asphyxia, to asthenia, or to a com- 
bination of these conditions. 

The expectoration of laminated casts of the bronchial tubes is an event 
which may naturally be looked for in cases of diphtheria in which the 



366 



DISEASES OF THE RESPIRATORY ORGANS. 



diphtheritic process has travelled from the larynx into the trachea and 
thence downwards. And, indeed, since the diphtheritic pellicle may form 
upon any part of any mucous membrane, there is little doubt that it occa- 
sionally forms in the smaller bronchial tubes independently of any such 
affection of the larynx, trachea, or bronchi, and that equally under these 
circumstances, expectoration of casts may take place. But occasionally 
such casts are spat up from time to time by patients, whom there is no 
reason to suspect of diphtheria. The causes, pathology, and symptoms of 
this affection, which has been termed ' plastic bronchitis,' are alike obscure. 
All that is positively known is, that persons, after a longer or shorter 
period of ill-health, and symptoms something like those of slight chronic 
bronchitis or lobular pneumonia, expectorate either without warning or 
after prolonged dyspnoea, and as the result of a more or less suffocative 
paroxysm of cough, a larger or smaller quantity of this material, often in 
connection with haemoptysis, which may be profuse, or with muco-purulent 
discharge ; that this plastic expectoration may then cease or may continue 
off and on for an indefinite period ; and that, although some of these pa- 
tients die ultimately of phthisis, and some of the accidents which attend the 
process of expectoration, the majority appear to make a good and perma- 
nent recovery. There is good reason to believe that the portions of lung- 
tissue to which the obstructed tubes lead are in a state of more or less 
complete collapse or lobular pneumonia; and indeed, although in most 
cases there appears to have been perfect pulmonary resonance with more 
or less rhonchus and crepitation, a few have been recorded in which, as 
might be expected, there was circumscribed dulness, with total absence of 
respiratory murmur over the dull area. The coexistence, however, of pul- 
monary and bronchial lesions does not explain the nature of the relation 
between them. There is no doubt that, in haemoptysis, blood occasionally 
coagulates in the bronchial tubes, and that in pneumonia bronchial casts of 
the same material as fills up the air-cells are now and then produced, but 
these seem to be quite distinct from the casts of plastic bronchitis, which 
probably originate in situ. 

Treatment — Bronchitis is one of the commonest diseases of temperate 
climates, one of the most frequent sources of incapacity for useful work 
and the enjoyment of life, and one of the most fruitful causes of death. 
Its treatment is therefore a matter of grave importance. It will be conve- 
nient to discuss it under different heads. Hygienic treatment. — This 
comprises the keeping of the patient in an equable and moderate tempe- 
rature, not below 65° or 66°, and, if possible, not very largely exceeding 
this, and preferably, therefore, confining him to the house or even to one 
room; the maintenance of some degree of moisture of atmosphere; the 
use of hot baths, the Turkish bath, or the hot pediluvium ; and the regu- 
lation of the diet according to the patient's capabilities and needs. Local 
treatment — Under this head may be included : first, treatment applied to 
the skin, inclusive of counter-irritation by mustard plasters, blisters, and 
the like, dry-cupping, and the abstraction of blood either by leeches or 
cupping-glasses ; second, treatment applied to the mucous membrane, such 
as the inhalation of steam, either simple or medicated with some of those 
substances which have been enumerated in the treatment of laryngitis. 

Medicinal treatment The drugs which have been employed are various. 

Among expectorant or nauseating medicines, ipecacuanha, squills and 
tartar emetic hold a high place ; stimulant drugs, such as the gum resins 
and balsams, more particularly benzoin, tolu, guaiacum, and ammoniacum, 



BRONCHITIS. 



367 



are often valuable ; and as closely related in action to these may be enu- 
merated ammonia, senega, and the stimulant vegetable tonics. Sedatives 
and narcotics, such as opium, conium, belladonna, and hyoscyamus are of 
great importance ; and in certain stages and in certain cases so also are 
sulphuric ether and lobelia. Lastly, tonics and alcoholic stimulants are 
often, and especially in the later stages of the acute affection, and in chro- 
nic cases, of extreme value. 

In ordinary mild bronchitis, little or nothing is needed beyond keeping 
the patient in a warm room, the inhalation of steam, the application to the 
chest of a mustard plaster, the use of the hot bath or pediluvium, the 
exhibition of small quantities of opium and ipecacuanha, and the relief of 
thirst and dryness of mouth by warm diluent drinks. 

In acute cases of greater severity, it maybe necessary to abstract blood 
from the surface of the chest. This can only be needed when there is 
extreme difficulty and pain in breathing, especially if at the same time 
there is reason to believe that the bronchial membrane is congested and 
swollen, and yielding but little secretion. The quantity of blood to be 
removed must be determined by the age and state of the patient, and by 
the effect of its removal. It is much better, however, to withdraw an 
adequate quantity at first than to repeat the operation over and over again. 
In such cases, too, counter-irritants and inhalation are of great value. As 
regards medicines, antimony or ipecacuanha in nauseating doses, combined, 
it may be, with squills, and above all with small doses of opium, and fre- 
quently administered, is generally useful. When the bronchial secretion 
becomes abundant and muco-purulent, these may still be continued, or 
may be replaced by the more stimulating forms of expectorant medicines. 
In this stage the combination of drugs recommended by Dr. Stokes, 
namely, ammonia, opium, and senega, is often of much service, as also are 
the balsams or gum-resins. When the patient suffers much from bronchial 
accumulation, an occasional emetic dose of ipecacuanha may be resorted 
to with benefit. Under similar circumstances, the persistent use of tartar 
emetic, in pretty large doses, associated with alcoholic stimulants, is fre- 
quently of great value. In protracted cases, and during convalescence, 
tonics are called for, and good nutritious diet. Few drugs are more valu- 
able than opium in the treatment of bronchitis ; it relieves pain and dis- 
tress, diminishes the irritability of the mucous membrane and the need for 
coughing, and probably also tends to reduce inflammation. At the same 
time its administration is often fraught with danger. It is generally best 
to give it in frequent small doses ; and it is well to give it very cautiously 
or to withhold it entirely when the patient shows signs of imperfect aera- 
tion of blood, when his bronchial tubes are overloaded with mucus, or 
when he tends to ramble. 

In chronic bronchitis, especially when exacerbations are present, the 
treatment must in the main be the same as that of the acute affection. On 
the whole, however, the abstraction of blood, and the use of medicines 
calculated to depress the patient's strength are not desirable. Counter- 
irritants, inhalation, stimulant medicines, tonics, and good diet are chiefly 
indicated. It is in these cases, too, that hygienic treatment is especially 
likely to be serviceable. The patient who is subject to a winter cough, in- 
creasing year by year in severity, and in whom emphysema and other such 
lesions are in progress, should dress warmly even in summer, should be 
careful not to expose himself to draughts or to the evening or early morn- 
ing air, should give up those pursuits which expose him to the causes of 



368 



DISEASES OF THE RESPIRATORY ORGANS. 



bronchitis, and should pass his winters on the South Coast, or on the shores 
of the Mediterranean, or in some other warm equable climate, or else con- 
fine himself to a room or suit of rooms, well-ventilated, but kept at a 
uniform and comfortably warm temperature. 



IV. PNEUMONIA. 

Causation — Inflammation of the substance of the lungs, like bronchitis, 
is due in the large majority of cases to the influence of cold and wet ; and 
it would seem that it may, under special circumstances, be caused either 
by brief exposure of portions of the heated surface of the body to a severe 
chill, or by prolonged exposure of the whole normally warm surface to 
comparatively slight degrees of cold. It is especially common in temper- 
ate climates, and at those seasons (spring more especially) when the 
temperature is liable to great variations. It may also be caused by the 
spread of inflammation (whether originally due to cold or hot) from other 
parts : as from the bronchial tubes, in cases of bronchitis, hooping-cough, 
measles, influenza, diphtheria, and the like ; from the pleura in cases of 
pleuritis ; or, if the pleural cavity be obliterated by adhesions, from the 
chest-walls or surrounding viscera. And again, it may be developed by 
the direct action of mechanical and other irritation, such as follows the 
inhalation of irritant gases, particles of dust or other such substances, 
solid bodies of larger size, vomited matters, or even water ; or it may 
spring from the presence of emboli in the branches of the pulmonary 
artery, or of tubercles or clots in the tissue of the lungs. 

There are also many pathological conditions — especially the presence in 
pulmonary congestion or oedema, or of specific poisons or effete matters of 
the blood — which favor the occurrence of pneumonia. And it is probably 
due to one or other or all of them that pneumonia is so common in the 
course of heart disease, kidney disease, various infectious fevers, erysipelas, 
rheumatism, and many other inflammatory disorders. It is also very apt 
to occur in persons advanced in syphilis, or worn out whether by disease 
or over-work. 

It must not be forgotten, however, that acute idiopathic pneumonia 
occurs with considerable frequency amongst those who seem to be in the 
best of health. This variety of the disease is met with at all ages and in 
both sexes ; but it is more common in men than in women, and far more 
common among the working classes than others — facts which are explica- 
ble by the relatively greater exposure to the causes of pneumonia of those 
who have to earn their livelihood by the sweat of the brow. A previous 
attack seems to predispose to subsequent attacks. 

Morbid anatomy — -It will be convenient, in describing the morbid 
anatomy of pneumonia, to distinguish, as has generally been done, two 
forms — namely lobar and lobular pneumonia, or, as they are termed by 
German writers, croupous and catarrhal. These names are none of them 
unobjectionable, and it might be better to replace them by the words dif- 
fused and patchy ; the type of the former variety being furnished by the 
idiopathic affection, that of the latter by the condition which is secondary 
to diseases of the air passages. The two varieties, however, pass into one 
another. 



PNEUMONIA. 



369 



A. Lobar pneumonia begins with hyperemia of the small vessels which 
are distributed in the walls of the air-cells and bronchial passages ; swelling 
and tendency to proliferation of the epithelial cells of these parts ; and 
exudation of inflammatory lymph (serum, albumen, fibrine), and of the 
corpuscular elements of the blood. The air- vesicles and passages commu- 
nicating with them gradually become filled, and finally distended with 
exuded matter, the air which they contained by degrees gets expelled, and 
the affected lung-tissue grows solid and heavy. If the parts be now 
examined microscopically, the dilated bloodvessels will be found to be 
crowded with their corpuscular contents, and the alveoli full of cells — some 
merely modified epithelial cells, with one, two, or more nuclei, some cells 
undergoing fatty change (in other words, granule-cells), and others having 
the characters of leucocytes or pus-corpuscles — all blended together into a 
common mass either by an amorphous glutinous cement, or by a delicate 
fibrillated network. The ordinary process of inflammatory cell-prolifera- 
tion has taken place, by means of which the epithelial cells have acquired 
a more or less distinct embryonic character; and to these, escaped leuco- 
cytes have been added. With the progress of the disease the contents of 
the air-vesicles liquefy, and acquire more and more both the naked eye 
and the microscopic characters of pus. The fatty degeneration which has 
been referred to may, either before or after the liquefaction of the contents 
of the air-vesicles, become general throughout the accumulated cells, which 
may then, if not expectorated, undergo gradual absorption. The conver- 
sion of the inflammatory exudation into pus is occasionally followed by 
the breaking down of the lung-tissue here and there into abscesses ; and 
occasionally by the concurrence of gangrene. It may be added that in- 
flammation of the lung, like inflammation of other parts, rarely if ever 
takes place without there being more or less abundant serous exudation 
into the surrounding uninflamed tissues ; and, further, that pneumonic in- 
flammation tends, like most inflammations, to spread. 

The progress of pneumonia through its various phases is quite gradual; 
nevertheless, there are at least three stages which severally present more 
or less obvious characteristic features. The first of these is the stage of 
engorgement, the second that of red hepatization, and the third that of 
gray hepatization. In the first stage the lung still contains air though in 
diminished quantity; it is deeply congested, exudes more moisture than 
natural, is increased in weight, and is more easily lacerable than healthy 
lung-tissue. This is the period of congestion and commencing prolifera- 
tion; and at this time the condition of the lung is scarcely, if at all, dis- 
tinguishable from that of simple hypostatic congestion. In the second 
stage the lung is consolidated ; it has lost its air, and its cavities are filled 
with coherent masses of cells ; it is distended to its full size, and its con- 
stituent lobules are distinctly mapped out upon the surface ; on section it 
appears to be pretty dry and slightly granular (a condition still more 
noticeable on the surface produced by laceration) ; and it presents a pecu- 
liar marbled aspect, w T hich is due to the intermixture of nearly colorless 
inflammatory deposit, patches of congestion, and the irregular slate-colored 
or black tracts which commonly stud the long-tissue of persons who have- 
reached adult age. The general hue of the lung is for the most part some- 
what pale ; there is probably, however, more decided congestion during 
life, and even after death the tissue is in some cases almost as deep in hue 
as we find it in pulmonary apoplexy. Sometimes, indeed, there is actual 
extravasation of blood. The lung-tissue is easily torn, and readily sinks 
24 



370 



DISEASES OF THE RESPIRATORY ORGANS. 



in water. The third stage differs from the second, mainly in the assump- 
tion by the affected lung-tissue of a pretty uniform opaque grayish, yellow- 
ish or greenish tinge, in its largely increased friability, and in the ready 
exudation from the cut surface of thick, turbid, purulent fluid. In some 
cases the fluid is comparatively scanty ; in some it is so abundant that the 
lung is like a sponge saturated with pus. 

We have already mentioned the fact that there is generally, if not always, 
considerable oedema of the lung-tissue beyond the part actually inflamed. 
We may add that there is almost invariably a deposit of inflammatory 
lymph on the surface of the inflamed portion of lung, as well as upon the 
parietal pleura in contact with it, and that this tends to diffuse itself over 
the serous membrane, more especially towards its base, but is not generally 
attended with any large amount of serous effusion. 

Since pneumonia tends to spread, it naturally follows that different por- 
tions of affected lung often present well-marked differences of condition, 
and that we occasionally find all the recognized stages of pneumonia pre- 
sent at the same time in the same case. Inflammation may involve the 
lung to very various extents : thus it may be limited to a patch no larger 
than a walnut, or may include an entire lobe or even a whole lung ; and, 
further, it may affect both lungs. It is curious how often it is strictly 
limited by the fissures or fibrous septa which separate lobes, and how often 
it is accurately mapped out by the margins of lobules. As regards position, 
it seems to be a well-established fact that the right lung is more frequently 
affected than the left, and the lower lobe than the upper. In reference to 
the latter point, however, it may be observed, that if we divide the lung 
horizontally midway between apex and base, there will be at least some 
two or three times as much lung-tissue below as there is above the plane 
of division, and that hence, if all parts of the lung be equally liable to in- 
flame, inflammation of the upper part should be several times less frequent 
than inflammation of the lower part. The forms of pneumonia which 
supervene on hypostatic congestion, or come on in the course of renal and 
cardiac disease, or complete pulmonary apoplexy and tubercle, differ little 
anatomically from that which has been here described. 

B. Lobular pneumonia is especially the pneumonia of young children ; 
it is not unfrequent, however, in older persons. In its best marked form 
the lung is studded with pneumonic patches, varying in size from about 
that of a pea to that of a filbert, and involving each one or more pulmonary 
lobules, circumscribed by the interlobular septa, and separated from one 
another by a network of still crepitant, and it may be perfectly healthy, 
lung-tissue. The pneumonic patches may be in the condition of engorge- 
ment simply, in which case their character may possibly fail to be recog- 
nized ; or they may present the ordinary features of red or gray hepatiza- 
tion. Further, by extension of disease, neighboring patches may coalesce, 
and thus extensive tracts of lung-tissue become involved. Lobular and 
lobar pneumonia here pass into one another True lobular pneumonia is 
always secondary to the blocking up of air-passages, and especially those of 
capillary size ; and it may be excited immediately either by the gradual 
extension of the inflammatory process from the tubes to the air-vesicles, or 
by the entrance into the vesicles during inspiration of inflammatory pro- 
ducts of the tubes which then act as irritants. But, whatever the cause, 
we find in the inflamed parts not merely overgrown and modified epithelial 
cells, but also, according to the stage of the disease, granular and embry- 
onic cells in greater or less proportion. The connection of lobular pneu- 



PNEUMONIA. 



371 



monia with obstruction of tubes is further shown by the facts, that lobular 
collapse is often associated with it, and that then the collapsed and pneu- 
monic conditions may often be seen to pass into one another by gentle 
gradation. 

Closely related to lobular pneumonia is the disseminated pneumonia due 
to obstruction of small branches of the pulmonary artery, either by embol- 
ism or thrombosis, or in the course of pyaemia. In these cases, as in the 
other, the affected patches are usually of small size, and limited by the 
margins of lobules. But there is greater variety of result, especially in 
pyaemia; in which, while the patches sometimes present simple engorge- 
ment, or red or gray hepatization, they not unfrequently are the seat of 
hemorrhage, or undergo rapid suppuration or gangrene. Lobular pneu- 
monia is generally best marked towards the basal portions of the lungs, and 
the superficial patches are often the centres of areae of pleural exudation. 

In all forms of pneumonia, even in such as are not of bronchitic origin, 
there is a tendency to the development, sooner or later, of more or less 
bronchitis. But, apart from this, there is a marked disposition early in 
the course of pneumonia, to the effusion into the tubes from the inflamed 
air-cells of a transparent, very viscid fluid, uniformly stained with blood, 
and containing corpuscular elements ; and, in some rare cases, this effusion, 
like that in the air-cells, whence it is derived, undergoes coagulation in the 
bronchial tubes, which thus become filled to a greater or less extent with 
casts consisting of coagulated fibrine and corpuscles. 

Notwithstanding the frequency with which pneumonia proves fatal, it 
does not very often go beyond the third of the stages which we have de- 
scribed ; sometimes, however, abscesses form, sometimes gangrene takes 
place, and sometimes the pneumonia lapses into a chronic condition. 
Pneumonic abscesses are usually of small size and irregular form ; and in 
some cases, especially when they are developed in connection with lobular 
pneumonia, the terminal bronchial tubules are primarily affected, their 
parietes become destroyed, and the abscesses taking their course assume a 
dendritic character. Gangrene very seldom occurs in simple idiopathic 
pneumonia; it is chiefly met with in those cases in which the pneumonia 
is secondary to or complicated with some other affection. It is character- 
ized by the breaking down of the lung-tissue into a fetid dirty greenish- 
yellow pulp, and by more or less greenish discoloration of the consolidated 
tissues around. Not unfrequently the latter are oedematous and present a 
slightly translucent aspect. The gangrenous condition may involve either 
an extensive tract of lung-tissue or several scattered patches, or even a 
single small patch. If it be recent at the time of post-mortem examination 
its margins will be found ill-defined ; if it have existed for some length of 
time the gangrenous cavity will probably be bounded by a well-defined 
edge. Of chronic pneumonia we shall speak at length hereafter. 

Of the associated morbid phenomena of pneumonia there are several that 
call for mention, if not for detailed description. We have adverted to the 
coexistence with it of pleurisy and bronchitis; but besides these, we fre- 
quently observe, an herpetic eruption on, or in the neighborhood of, the 
lips; more or less jaundice without obvious hepatic disease; intestinal 
congestion, with sometimes membranous patches on the mucous surface of 
the large intestine ; and inflammation of the bronchial glands. Further, 
the conditions which give rise to pneumonia occasionally give rise at the 
same time to inflammation of other organs. Thus accompanying pneu- 



372 



DISEASES OF THE RESPIRATORY ORGANS. 



monia we sometimes find inflammation of the brain, kidneys, bowels, or 
pericardium. It is common, after death, for the right side of the heart to 
be full of fibrinous coagulum which is prolonged into the pulmonary artery, 
while the left side of the heart is contracted and almost empty. 

Symptoms and progress — -Idiopathic pneumonia is frequently ushered 
in with a day or two of feverish or undefinable feeling of illness. The 
invasion of the disease is generally marked by a sudden and severe rigor, 
or a succession of rigors, or in children by an attack of convulsions — phe- 
nomena which are attended with a rapid and considerable elevation of 
temperature, and the usual symptoms of inflammatory fever. The specific 
signs of the pulmonary affection usually declare themselves immediately 
or in the course of the next four-and-twenty hours; very rarely they are 
delayed for a still longer period. They consist in rapidity and shallow- 
ness of breathing, with more or less dyspnoea; dorsal decubitis ; cough, 
soon attended with blood-stained glutinous sputum; pain probably in the 
affected side on drawing a deep breath; and, according to the stage which 
the pulmonary affection has reached, fine crepitation, or dulness with 
tubular breathing, and augmented bronchophony and vocal fremitus. While 
these local conditions are in progress, the patient's febrile state continues; 
his skin is hot and dry or perspiring, his tongue furred, his pulse accele- 
rated; jaundice is apt to come on, and diarrhoea; his urine is scanty and 
perhaps albuminous ; at the same time, probably, he suffers from more or 
less hebetude, with delirium, which comes on especially at night. The 
further progress of the case varies according to its severity. In very mild 
cases, after two or three days of illness, the patient's temperature falls, his 
other symptoms subside, and convalescence is established. In other favor- 
able cases convalescence may be delayed for a week, ten days, or a fort- 
night; and the amendment may then be either sudden or gradual. In 
cases which end fatally, death may occur at any period of the disease, 
even during apparent convalescence, and is due, as a rule, either to asthenia 
or to gradual asphyxia, or to a combination of these conditions. 

We will discuss seriatim some of the more important of the phenomena 
which attend pneumonia. 

The respirations are usually hurried and shallow, and may vary in rate 
from the normal up to 50 or 60 and upwards in the minute; when very 
rapid they are usually attended with a sucking sound in the mouth, and 
expansile movements of the alee nasi; there is often, but by no means 
necessarily, more or less severe dyspnoea, and generally there are signs of 
breathlessness when the patient attempts to speak. 

Cough, which is sometimes very troublesome and even paroxysmal, is 
almost always present. It is at first dry, but is soon attended with the 
expectoration of transparent and very viscid mucus, tinged with the coloring 
matter of the blood. This is usually said to have a rusty tint, and indeed 
often has; but it varies in color between a pale saffron and a bright ver- 
milion, and in the latter case may be mistaken, on hasty inspection, for 
pure blood. After retaining this character for a few days, the expectora- 
tion loses its sanguineous tint and becomes opaque and greenish — acquires 
in fact a muco-purulent character — and then gradually diminishes in quan- 
tity. In some cases, instead of undergoing this, which may be regarded 
as the normal change, it acquires a deep purplish or reddish-brown tint 
and at the same time a more watery consistence. This form of sputum 
has been likened to prune-juice, and is generally a sign not only of in- 
creased congestion and escape of blood, but of the access of the third stage, 



PNEUMONIA. 



373 



and of an unfavorable issue. In some cases, again, the expectoration 
becomes distinctly purulent, or is attended with the horrible fetor which 
usually indicates pulmonary gangrene. The quantity and quality of the 
expectoration vary remarkably in different cases. In some there is abso- 
lutely none from first to last; in some the patient never coughs up more 
than one or two rusty-colored sputa ; in some the expectoration, even if 
abundant, never presents the characteristic tint. Pneumonic expectoration 
is characterized by the presence of a superabundance of common salt, and 
contains a considerable quantity of mucus and albumen. 

There is much variety as to the presence and degree of thoracic pain. 
In some cases there is no pain whatever; in some there is a mere sense of 
heat; in some the patient has severe stitch whenever he coughs or draws a 
deep breath. This pain is pleuritic in character, and doubtless due to the 
coexistence of pleurisy. 

In the first stage of the disease the most characteristic auscultatory 
phenomenon is minute crepitation, which may be audible during the whole 
of inspiration, sometimes during expiration as well, and not unfrequently 
only at the end of a deep inspiration, such as that which precedes a cough. 
In association with this there may be no change on percussion, or there 
may be high-pitched resonance or bruit de pot fele. The second stage is 
marked by the supervention of dulness over the consolidated portion of 
lung, with increase of vocal fremitus ; cessation of fine crepitation, and the 
development in its place of well-marked tubular breathing, and the corre- 
sponding whining character of cough and voice; bronchophony; and in 
some cases pectoriloquy. There may also be sharp metallic crepitation or 
rhonchus. In some cases (probably when the bronchial tubes leading to 
the consolidated portion of lung are completely obstructed) there is almost 
total absence of respiratory sounds and bronchophony over the affected 
region. It need scarcely be pointed out that, in consequence of the co- 
existence of pleurisy, it is common to get friction sounds mixed up with 
those due to pneumonia, and possible even for the pneumonic sounds to be 
suppressed or replaced by the phenomena indicative of pleurisy. At a 
later stage, when lung-tissue is breaking down, or resolution is taking place, 
tubular breathing gives way to a kind of coarse crepitation, to which the 
name of crepitatio redux has been given. This gradually passes into the 
ordinary bronchitic rales. It may be added that, when the pneumonic 
lung is consolidated, the movements of the thoracic walls in relation with 
it become impaired, and the resistance on percussion manifestly increased; 
and, further, that pneumonia may be present, deep-seated in the lung, or 
limited to its diaphragmatic or inner surface, and thus altogether escape 
detection by auscultation or percussion. Some degree of dulness on per- 
cussion usually persists long after the disappearance of the other local signs 
of pneumonia. 

The cardiac pulsations are always increased in frequency during the 
febrile stage of the disease, but rarely increased proportionately to the 
respirations. Often indeed their ratio, instead of being about 4 to 1, sinks 
to 2 or 11 to 1. In adults the pulse may range from 80 or 90 up to 120 ; 
in children it is generally more rapid, and may rise to 200 and upwards. 
Extreme rapidity is generally associated with feebleness, and not unfre- 
quently with irregularity, and is hence to be regarded as an unfavorable 
sign. In the beginning the pulse is often somewhat full and strong, but 
sometimes full, soft and dicrotous ; later on it always becomes more or less 
feeble and dicrotous. During convalescence it may fall below the normal 



374 



DISEASES OF THE RESPIRATORY ORGANS. 



frequency. While pneumonia is in progress the systemic veins are apt to 
get overloaded, and the surface may assume a dusky hue. The blood 
always presents a large excess of fibrinogen. 

The tongue is coated, and in some cases becomes dry and brown, and 
sordes accumulate upon the teeth. Thirst is pretty constant ; there is 
always loss of appetite, and occasionally sickness. The bowels vary ; 
sometimes they are not particularly affected throughout the disease ; some- 
times they are constipated ; sometimes, on the other hand, there is more 
or less profuse diarrhoea, and this may be dysenteric in character. The 
occurrence of jaundice during the progress of pneumonia is neither uncom- 
mon, nor very important. It is said to occur most frequently in those 
cases in which the right lower lobe is affected. But there is no more 
necessary connection between right pneumonia and jaundice than between 
left pneumonia and it. 

The urine is scanty, dark-colored, and of high specific gravity, present- 
ing a diminished quantity of chloride of sodium and a great excess of urea 
and uric acid, with a tendency to the deposition of urates. Sometimes it 
contains also a little albumen, with hyaline, granular, or epithelial casts. 
During convalescence it gets much more abundant, pale, and of low specific 
gravity; and the urea undergoes diminution, while salt increases. 

The face is more or less flushed in the early period of pneumonia, and 
may even be somewhat livid ; the skin is generally hot and dry ; but pro- 
fuse sweats are not uncommon during the progress of the disease, and 
generally attend its decline. An herpetic eruption about the lips and alee 
nasi is almost pathognomonic. 

The patient at first complains of headache and general febrile pains. 
He is often drowsy, yet, at the same time, restless, especially at night 
time. Delirium is apt to come on early, at first being limited to the night, 
but subsequently becoming more or less constant. In some instances, and 
mainly in persons who have been given to drink, the nervous symptoms soon 
assume all the characters of delirium tremens. And again, patients, not 
otherwise obviously affected in mind, occasionally get suddenly and vio- 
lently maniacal, the paroxysm possibly abating as suddenly as it arose. In 
fatal cases delirium is apt to pass into coma. Muscular tremors and sub- 
sultus, with loss of control over the bladder and rectum, are frequently 
observed in severe cases. 

The temperature rapidly rises from the time of invasion, so that within 
a few hours, at most perhaps twelve, it has almost attained its maximum ; 
this varies from 100° to 106°, or even more. Thenceforward the tem- 
perature remains high, probably increasing somewhat, with morning 
remissions and evening exacerbations, until the time of commencing con- 
valescence, when it suddenly or gradually falls. In the former case it may 
sink to the normal or below it in the course of twenty-four hours. Occa- 
sionally in fatal cases the temperature rises rapidly before death. 

The symptoms of uncomplicated idiopathic pneumonia are collectively 
so characteristic of the disease that it is almost impossible to mistake their 
significance. The affections, other than those of the respiratory organs, 
with which it is most liable to be confounded are typhus and enteric fevers. 
No real difficulty, however, can arise unless the specific characteristics of 
these fevers be in abeyance, and they be at the same time (as they often 
are) complicated with secondary pneumonia. It is altogether different, 
however, in respect of the various forms of intercurrent or secondary 
pneumonia, and of the lobular variety of the disease. These creep on, 



PNEUMONIA. 



375 



for the most part, insidiously in the course of other grave affections, which 
have already probably produced serious pulmonary symptoms, such as 
dyspnoea, cough, expectoration of serous, mucous or bloody sputa, lividity 
of surface, and other indications of embarrassed circulation and carbonic 
acid poisoning ; their onset is not usually marked by rigors or anything 
equivalent to rigors, nor is their progress usually attended with the high 
febrile disturbance which characterizes the idiopathic variety ; and, again, 
they are not often accompanied by labial herpes, or jaundice, and very 
often there is, excepting towards the close of the disease, an entire absence 
of delirium. The supervention of these forms of pneumonia may be sus- 
pected, in patients suffering from the various diseases which are apt to be 
complicated by them, when their symptoms, and especially those referable 
to the respiratory organs, become aggravated ; but they can only be posi- 
tively determined by careful physical investigation of the condition of the 
thoracic organs. It must not be forgotten, however, that lobular pneu- 
monia may be present to a considerable extent without producing either 
the characteristic dulness, the tubular breathing, or the other specific signs 
of the more uniformly diffused variety of the disease. The auscultatory 
and percussive phenomena indeed may differ little if at all from those 
which attend capillary bronchitis. 

The breaking down of portions of lung-structure which occasionally at- 
tends the later stages of pneumonia does not reveal itself by any special 
sign, unless the cavities be such as, from their size or position, to give rise 
to characteristic auscultatory phenomena. In rare cases such abscesses 
burst into the pleura, or (the lung being adherent) perforate the thoracic 
walls, or form sinuses running down behind the peritoneum, and opening 
ultimately into the colon or some of the hollow viscera of the pelvis. The 
occurrence of gangrene is usually revealed by the disgusting fetor of the 
breath, especially during the processes of coughing and expectoration, and 
in a less degree by the look and smell of the sputa. Here also the cavi- 
ties due to the destruction of lung-tissue may perhaps admit of detection. 
The presence of gangrene is generally attended with marked depression of 
the vital powers, or, in other words, collapse. 

Pneumonia is always a disease of considerable gravity. Still, in its 
idiopathic form, it comparatively rarely kills, unless the portion of lung 
involved be extensive, or both lungs be attacked, or except in the case of 
persons advanced in years, or of those whose constitutions have been in- 
jured by long-continued bad habits, over-work, or disease. The secondary 
form of the disease, and especially the lobular variety, on the other hand, 
are exceedingly fatal, and may be included among the chief immediate 
causes of death in the various maladies which they complicate. 

Treatment — There are few diseases for which so many opposite plans 
of treatment have been employed with reputed success as for pneumonia. 
It is a disease, too, which, more perhaps than any other, has on this very 
account been appealed to in proof of the change of type of disease. From 
the time of Laennec to about the middle of the present century almost im- 
plicit reliance was placed in the combined use of blood-letting, antimony, 
and mercury. Since then, especially dating from the time of Dr. Todd, 
these remedial agents have been to a very large extent discarded, and 
have got replaced by the free exhibition of alcoholic stimulants. Many, 
indeed, now regard all medicinal treatment as of little or no importance; 
and it is quite certain that a large number of even severe cases recover 
perfectly if left to nature and the nurse. 



376 



DISEASES OF THE RESPIRATORY ORGANS. 



In the majority of cases of the idiopathic disease it is probably quite 
sufficient to keep the patient in bed in a comfortable, well-ventilated room, 
of medium temperature; to relieve thoracic pains with mustard plasters 
and the like; to assuage febrile thirst by the exhibition of soda-water, 
orangeade, or lemonade ; to support strength by the frequent administra- 
tion of milk or gruel, or some equivalent nutritious fluid £ and to relieve, 
from time to time, by simple measures, diarrhoea or constipation, and other 
remedial derangements of the various organs ; and then, as convalescence 
comes on, to give vegetable tonics, and gradually to improve the diet in 
respect of both quantity and quality. It is doubtless true, however, that, 
in many cases, the above plan of treatment may be judiciously supple- 
mented by other measures. Bleeding from the arm, or the local abstrac- 
tion of blood from the chest by cupping or leeches, is certainly followed by 
relief to symptoms when employed early in cases in which there is high 
fever and much dyspnoea. We believe that bleeding from the arm is more 
efficacious than the other methods of bleeding, but in any case it is better 
to remove sufficient blood at a single operation than to be called upon to 
repeat it. Counter-irritants and detergents are often serviceable at a later 
period of the disease, or at the beginning of slight cases in which bleeding 
is not deemed necessary. They relieve pain, and sometimes diminish diffi- 
culty of breathing. Dry cupping is of especial value. Some physicians 
think it well to keep the affected side invested in a large poultice or a layer 
of cotton-wool ; others prefer the application of ice-bags or cold compresses. 
We do not think that any benefit accrues from the former plan, but the 
latter probably has some advantage. Expectorants, such as ipecacuanha 
in small doses, may possibly aid those cases in which there is frequent 
and troublesome cough, with difficulty of expectoration ; and, under the 
same circumstances, the addition of a small quantity of opium may be 
serviceable. 

"When the pulse gets very quick and weak, and delirium is established, 
especially if the patient present the general symptoms of delirium tremens, 
diffusible stimulants, such as ammonia, and alcoholic drinks, in quantities 
to be determined by their effects, are indispensable. It may be added 
that, with the object of reducing temperature, various agents have been 
recommended ; and possibly one or other of them may sometimes be used 
with advantage ; among these may be enumerated cold baths, quinine in 
large doses, salicylic acid, veratria, digitalis, and aconite. The occurrence 
of suppuration or gangrene is a special reason for the maintenance of the 
patient's strength by nutritious food, stimulants, and tonic medicines. 
Opium is often of great service, but should not be given, or should be 
given very cautiously, when the patient is suffering from dyspnoea and in- 
sufficient aeration of the blood. The treatment of secondary pneumonia 
merges in the treament of the disease it complicates. Its supervention, 
however, is on the whole a plea, not for depletion, but for the opposite 
plan, namely, the use of stimulants and of nourishment. 



Y. PLEURISY. (Plevritis.) 



Causation Pleurisy is either idiopathic, or the result of local irritation. 

The former class of cases includes pleurisy arising directly from exposure 



PLEURTSY. 



377 



to cold — the form of pleurisy which corresponds to idiopathic pneumonia 
and bronchitis — and that which takes place in the course of acute rheu- 
matism. Among the latter class may be enumerated, pleurisy due to 
extension of inflammation from inflammatory and other affections of the 
lungs, or thoracic parietes; that due to mechanical injuries, more especially 
to the rupture into the pleura of pulmonary cavities, or of abscesses of the 
liver or other neighboring organs ; as also probably the pleurisy which is 
so commonly associated with the progress of pulmonary phthisis and 
thoracic carcinoma. In addition to the varieties of pleurisy here enu- 
merated must be mentioned those which are developed in the course of 
smallpox, scarlatina, enteric fever, pyaemia, albuminuria, and heart dis- 
ease, and in respect of which these several affections act variously, some- 
times as exciting, sometimes, and perhaps more frequently, as predisposing 
causes. 

Morbid anatomy. — Inflammation of the pleura, like that of all other 
serous membranes, commences with hyperemia of the bloodvessels, pro- 
liferation of the protoplasmic elements of the tissues, more especially the 
epithelium, and effusion of inflammatory lymph, comprising various but 
pretty considerable quantities of albumen, fibrine, and corpuscles. The 
last two for the most part remain adherent to the surface, forming the so- 
called * false membrane;' the fluid, containing albumen, fibrinogen, and a 
variable proportion of corpuscles, accumulates within the serous cavity. 
The inflammatory process combines, therefore, three elements, which may 
conveniently be considered independently of one another, namely — first, 
hyperemia and infiltration of the serous and sub-serous tissues; second, the 
formation of a false membrane; and, third, the effusion of serum. 

The first of these elements is the first in order of development ; -but it 
seldom attains a high degree or forms a prominent item in the collective 
inflammatory changes. There is always, however, more or less obvious 
infiltration — its amount having some relation to the intensity of the in- 
flammatory attack ; and this not unfrequently extends into the connective 
tissue round about, as, for example, along the interlobular septa of the 
lungs, and into the tissues of the mediastina, diaphragm, and external 
thoracic parietes. And thus it occasionally happens that the superficial 
stratum of lung-tissue becomes involved, that the diaphragm and intercostal 
muscles suffer, and that inflammation, commencing in one serous cavity, 
extends to those which are in its immediate vicinity. 

The effusion of inflammatory lymph always begins early. At first it 
constitutes an exceedingly thin, granular, but more or less coherent pellicle, 
the presence of which renders the serous surface obviously rough to the 
finger and deprives it of its polish. This gradually extends in area and 
increases in thickness, usually becoming at the same time more and more 
yellow and translucent. The thickness which it may attain varies roughly 
from that of a mere film up to half an inch or even an inch. The charac- 
ter of its surface presents numerous varieties, which depend partly on the 
tendency of the lymph itself to be deposited in the form of a network, 
partly on the attrition to which it is exposed during the movements of the 
opposed surfaces upon one another, and partly on its stickiness. It thus 
acquires a, more or less irregular ribbed, villous, or retiform character. 
When the opposed surfaces of an inflamed pleura are separated by fluid 
effusion it often happens that trabecular and bands or septa of inflammatory 
lymph pass irregularly between them. The attached surface of the false 
membrane is always closer in texture and tougher than its free surface. 



378 



DISEASES OF THE RESPIRATORY ORGANS. 



and becomes with age more and more firmly united to the proper serous 
membrane, with which indeed it ultimately gets incorporated. It is here, 
too, that organization, with the formation of new bloodvessels, commences 
— a process which, if the case go on favorably, ultimately pervades the 
entire thickness of the false membrane, and leads to the blending of the 
opposed layers, to their conversion into connective tissue, and to the ob- 
literation of more or less of the pleural cavity. 

The fluid effusion varies greatly in quantity relatively to the other two 
products of the inflammatory process. It is difficult in many cases to ac- 
count for this fact, but occasionally it is explicable in some degree on 
mechanical grounds. In the first instance the fluid is transparent, yel- 
lowish or greenish, and probably presents flakes of lymph floating in it. 
In many cases it retains this character throughout ; but in some it becomes 
turbid or opaline, and deposits a little milky sediment on standing. Oc- 
casionally it acquires the characters of ordinary pus. It may be added that 
blood is sometimes extravasated, either from rupture of the new-formed 
vessels of the false membrane or from ulcerative destruction of the subja- 
cent lung-tissue; that gas is occasionally present — an occurrence due either 
to an external wound or to some communication between the lung or in- 
testine and the pleura ; and lastly, that the purulent contents occasionally 
get fetid. The quantity of fluid effused may vary from almost zero up to 
two or three quarts. 

In a large number of cases, especially those in which the pleurisy is due 
to the extension of inflammation from subjacent parts — as for example y 
when it arises in the course of peritonitis, pericarditis, lobar pneumonia, or 
the various forms of disseminated pneumonia — the discharge of serum is 
very scanty, and the lymph forms a thin film, which may be limited to the 
area primarily involved, and that opposed to it, or may gradually creep 
over the whole pleural surface. Moreover, in such cases it is far less liable 
to spread from below upwards than from above downwards ; but generally 
even in slight cases with little effusion it is common for the inflammatory 
products (solid as well as fluid) to subside to the most dependent part of 
the pleural cavity and to accumulate there. 

In other cases, and more particularly, perhaps, in the idiopathic form of 
the disease, in those varieties of it which attend smallpox and other erup- 
tive fevers, or tuberculosis, and in that due to perforation of the pleura by 
abscess, effusion takes place rapidly and copiously. The effects of the 
accumulating fluid are the distension of the pleural cavity, the compression 
of the lung, and the displacement in different degrees of the surrounding 
organs. As the fluid rises in the thorax, more and more of the lung, 
commencing with its lower part, has its air squeezed out of it. Subse- 
quently, perhaps, the whole organ suffers, and consequently becomes 
remarkably reduced in size, and compressed into the neighborhood of its 
root and the upper part of the angle between the vertebrae and ribs. 
There, in fact, it may lie concealed from view by a layer of lymph con- 
tinuous with that lining the thoracic parietes ; and the unskilled patholo- 
gist might at first sight readily assume that the lung had undergone total 
destruction. If the lung have been the seat of consolidation, or if it have 
been previously bound to the parietes here and there by old adhesions, or 
if the distension of the pleura with fluid be incomplete, the compressed 
lung will probably hang or protrude more or less irregularly into the 
pleural accumulation. The abundant presence of fluid causes, in addition 
to compression of the lung, displacement of the heart and mediastinum 



PLEURISY. 



379 



towards the opposite side (especially observable when the left pleura is 
affected), depression of the diaphragm, and expansion of the outer parietes 
of the thorax, with widening and probably bulging of the intercostal spaces. 

When suppuration (empyema) takes place (an occurrence of special 
frequency in the pleurisy of smallpox, scarlet fever, measles, and pyaemia, 
and in that of women who have just undergone childbirth, or from per- 
foration), all the phenomena just described naturally ensue ; but others due 
to the presence of pus will probably be superadded. The abscess sooner 
or later tends to point. Not unfrequently it opens into the lung; and often 
it makes its way through the thoracic parietes, forming, in the first in- 
stance, a sinus between the ribs, which probably become to a greater or 
less extent exposed and carious ; then an accumulation between the ribs 
and the integuments, which, gradually enlarging, may develop, ere an ex- 
ternal opening takes place, into a large superficial abscess. The route 
which such a sinus may take and the point at which it may present, are 
liable to great variety. Thus sometimes the abscess appears at the upper 
part of the thorax and even above the clavicle ; sometimes it opens in the 
loin below the level of the twelfth rib. Much more frequently, however, 
it occupies some intermediate position. In rare cases the empyema per- 
forates the diaphragm, and it may then take the course of a renal or psoas 
abscess, and finally open in any of the situations in which such abscesses 
are liable to open. 

The ultimate consequences of pleurisy are various. In the great majority 
of cases the fluid accumulation undergoes absorption, the partially-com- 
pressed lung recovers itself, and the effused lymph is slowly converted into 
a kind of cicatricial connective tissue, which remains permanently. This 
may ultimately constitute a mere white opacity upon some portion or 
portions of the pleural membrane; or, what is far more common, result in 
the formation of adhesions between the opposed surfaces. The latter may 
consist in a mere intervening film of connective tissue, or in groups of 
filaments and bands of various lengths, or in tissue as close, dense, and 
tough as cartilage or tendon, and wdiich in process of time may become the 
seat of calcareous deposit. Adhesions may be limited to one or two points 
only, or, may be generally but irregularly distributed, or may involve the 
whole extent of the pleura, the cavity of which then ceases to exist. 

When the lung has long been compressed by fluid (whether serum or 
pus), and rendered entirely airless, especially if at the same time it has 
been covered with a thick dense layer of false membrane, the absorption 
or removal of the fluid is probably attended with little or no restoration of 
the lung; and the space which that organ occupied becomes filled up by 
the falling in of the surrounding parts. The mediastina and the heart are 
drawn over towards the affected side ; the corresponding half of the dia- 
phragm rises, carrying with it the stomach or the liver, as the case may 
be ; the ribs get retracted and approximated ; the shoulder falls ; the spine 
bends in the same direction; and the patient's carriage undergoes a cor- 
responding change. At the same time the adhesions probably remain 
abundant and thick, and sometimes oedematous. In many cases, on the 
other hand, when compression has been less complete, or the adhesions 
are less strong, convalescence, even after an extreme amount of pleural 
effusion, is attended with more or less restoration of the affected lung — an 
event which often requires considerable time for its completion. In some 
such cases, when death has ensued before the entire removal of the fluid, 
the lung is found to be invested in a fenestrated layer of pretty dense false 



380 



DISEASES OF THE RESPIRATORY ORGANS. 



membrane, which by the general pressure it exerts renders the organ 
irregularly rounded, while the fenestras permit of irregularly distributed 
tabulated protrusions of crepitant lung-tissue. 

An empyema may, after the discharge of its contents, be followed by 
any of the consequences above enumerated ; but, like other deep-seated 
abscesses, its cavity often fails to get wholly obliterated, and a sinus 
results, through which it continues to discharge for an indefinite period. 
This tendency for an empyema to remain open is occasionally traceable 
to a carious condition of the ribs. On the other hand, circumscribed 
collections of pus here, as elsewhere, sometimes dry up into caseous 
masses. 

Lastly, inflammation may attack a pleura already partially or wholly 
obliterated by adhesions. In the latter case, the consequences will prob- 
ably be congestion, infiltration, and thickening of the pre-existing false 
membrane. In the former case, the effused serum or pus will occupy 
either a more or less definitely circumscribed space or the whole pleural 
cavity, divided by bands and septa into a series of inter-communicating 
loculi. Such limited accumulations of fluid are occasionally met with in 
the interlobular fissures, or between the diaphragm and base of the lung, 
or between the inner aspect of the lung and the mediastina — situations in 
which they often escape recognition during life. 

Symptoms and progress The symptoms of pleurisy present great 

variety, both in intensity and in kind — the differences being due mainly 
to differences in the extent, position, and intensity of the inflammation, 
in the circumstances under which it is developed, in the diseases with 
which it is associated, and in the stage at which it has arrived. The spe- 
cific symptoms, nevertheless, are simple enough, and, in addition to the 
signs furnished by percussion and auscultation, principally comprise tho- 
racic pain during respiration, dyspnoea, and inflammatory fever. 

The invasion of idiopathic pleurisy is far from uniform in its symptoms. 
In some cases the patient complains only of a little feverishness, loss of 
appetite, and general malaise, together with a stitch or pain in one side 
when he breathes deeply, or coughs, or twists his body or moves the cor- 
responding arm ; and he may continue to follow his ordinary avocation 
until, in the course of a week or two, or more, he is restored to health, or 
until, at the end perhaps of an equally long time, increasing illness and 
difficulty of breathing make him consult a medical man, who may possibly 
then find the implicated side distended with fluid. In other cases the pa- 
tient is suddenly seized with rigors, or (and this may occur even in adults) 
an epileptiform attack, followed by high febrile symptoms and the character- 
istic stitch. In other cases, again, after he has complained for a day or two 
of some degree of feverishness and pain in the side, the symptoms, both 
local and febrile, assume sudden intensity. 

But, however the disease comes on, whether with rigors or with none, 
whether slowly and insidiously, or by sudden onset, it rarely happens, un- 
less it be suppurative from the beginning or dependent on the presence of 
some blood-poison, that the temperature rises above 102° ; often, indeed, 
it does not exceed 100° ; and it may be scarcely above the normal. The. 
condition of the pulse and the other general symptoms have some relation 
with the temperature. The pulse is generally full and vibratile or dicro- 
tous, and somewhat increased in frequency, the skin is hot, the tongue more 
or less furred, the appetite impaired, the thirst increased, the urine scanty 
and high-colored, and the bowels confined. There are probably also head- 



PLEURISY. 



381 



ache and general febrile pains. From the beginning the patient has a stitch 
which is usually referred to the mammary region, and the presence of which 
renders deep inspiration and all thoracic movements painful, so that the 
breatli becomes hurried, shallow, perhaps irregular, and frequently attended 
with an expiratory groan, and the patient avoids all unnecessary movement. 
There is usually also some tenderness on pressure and percussion of the 
affected side. 

While these symptoms are present and the pleurisy remains in the 
so-called ' dry stage,' percussion may perhaps reveal some little dulness 
at the base of the pleural cavity, and auscultation may detect, here or 
elsewhere, some variety of friction-sound. Cough is often absent, and, 
when present, dry, or attended only with a little frothy expectoration. 
It is rarely severe, but is sometimes paroxysmal and troublesome, and 
always painful. 

As effusion increases, the pleuritic stitch for the most part diminishes, 
and may at length wholly disappear. Meanwhile the febrile temperature 
and general symptoms of illness may remain at the same level, or undergo 
some diminution. Dyspnoea may or may not increase ; and it is an im- 
portant fact that the effusion of sufficient fluid to distend the pleural cavity 
is in some cases attended with little or no obvious dyspnoea so long as the 
patient remains at rest. On the whole, however, dyspnoea increases with 
increase of fluid accumulation ; and the patient not only breathes rapidly, 
but suffers from much distress and anxiety, gets pale or livid, even to cyan- 
osis, and presents all the phenomena of slow asphyxia. The presence of 
fluid in the pleura is indicated : by dulness on percussion up to the level 
at which the fluid stands — the* level, in many cases, distinctly varying, in 
relation to the different points of the thoracic walls, with the patient's 
movements ;, by suppression of vocal fremitus over the dull part ; and gene- 
rally by absence of respiratory sounds over the same region. Faint tubu- 
lar sounds, however, or even an indistinct vesicular murmur is occasionally 
audible. iEgophony is usually to be heard about the angle of the scapula ; 
sometimes, also, friction-sounds above the level of dulness, especially in 
front ; and high-pitched resonance and the bruit de pot fele over the un- 
compressed portion of lung. 

AYhen the effusion fills the pleural cavity, and the lung is wholly com- 
pressed, dulness of the side, with absence of vocal fremitus, becomes gene- 
ral, and both aegophony and respiratory sounds cease. The last, however, 
may generally still be heard about the apex, in front and behind, and thence 
downwards behind, between the scapula and spine. But, in addition to 
these phenomena, the heart becomes displaced, the diaphragm thrust down, 
the side distended and almost immovable, with dilated intercostal spaces, 
over which, by careful manipulation, fluctuation may sometimes be detected. 

Convalescence may commence at any stage. In a large proportion of 
cases, the patient begins to recover before there has been any obvious effu- 
sion of fluid ; pain in the side gradually ceases, febrile symptoms (if there 
be any) subside, and friction slowly vanishes. In other cases convalescence 
does not commence until after fluid has accumulated, and more or less of 
the lung has been compressed. Here, again, convalescence is indicated by 
subsidence of fever and general improvement in the condition of the pa- 
tient's bodily functions; his breathing becomes more natural, and his 
appetite returns. At the same time the effused fluid is gradually absorbed, 
the pleural surfaces come again into contact and consequently pain may 
return temporarily and friction be re-established. Indeed, friction is often 



382 



DISEASES OF THE RESPIRATORY ORGANS. 



a more marked phenomenon of convalescence than of the early stage of the 
disease. It may happen that, with the disappearance of the fluid, the lung 
enlarges, and healthy respiratory sounds are speedily restored ; but, even 
in favorable cases, it is usually a long time (it may be months) before 
friction wholly disappears, and even longer before resonance and respiratory 
sounds return to the basal portion of the affected side of the chest. In less 
favorable cases, the lung is restored in part only, or remains permanently 
collapsed. Then all those changes in the form of the side and arrangement 
of internal organs, which have been already described, ensue. But even 
here some improvement may be hoped for in the course of years. The 
patient, however, usually remains weakly and short of breath. 

The common cause of death in simple pleurisy is asphyxia due to the 
pressure of the accumulated fluid; the patient may die, however, from 
syncope or asthenia, and in either case death is apt to take place suddenly. 

The supervention of suppuration — the development of empyema — is often 
insidious and unattended with either the aggravation of old symptoms or 
the occurrence of new ones. The simple long persistence of copious effu- 
sion affords presumptive evidence of suppuration. Suppuration is generally 
indicated also when there has been, from the beginning of the attack, 
much fever, and rapid filling of the side with fluid ; and especially when, 
in the course of a case hitherto of only moderate severity, rigors occur, 
and fever, becoming greatly augmented, continues augmented. The local 
indications of empyema are not necessarily more pronounced than the 
general symptoms. In addition to those of distension from mere accumu- 
lation, we sometimes observe general or partial oedema of the integuments 
on the affected side, sometimes distinct bulging of the intercostal spaces, 
sometimes unnatural distinctness of the superficial veins, and sometimes 
a circumscribed redness and induration, or a fluctuating swelling superficial 
to the ribs, due to the escape of matter from the pleural cavity through an 
intercostal space into the soft tissues beneath the integuments. We have 
pointed out that an empyema may burrow in almost any direction and 
discharge itself at almost any surface ; the most important practical term- 
inations of this kind, however, are by perforation of the lung and by per- 
foration of the thoracic parietes. In the former case the patient suddenly 
expectorates a large quantity of pus, and may continue henceforth to dis- 
charge pus, either continuously in comparatively small quantities, or at 
irregular intervals profusely. In the case of discharge through the tho- 
racic parietes, the abscess first points, and then opens either spontaneously 
or by operation, and as in the former case pus, in more or less abundance, 
escapes, and probably continues to escape. The sudden expectoration of 
pus, or the appearance of an abscess in the thoracic walls, is sometimes 
the first clear indication that there has been a circumscribed empyema. 
But it must not be forgotten that a superficial abscess often communicates, 
by a comparatively long and tortuous passage, with the internal abscess 
which gave it origin; and that hence (in the case of circumscribed empye- 
ma) it may be impossible to trace it back to its source, and make sure of 
its empyematic origin. Thus an abscess of the lower part of the pleura 
may be readily and pardonably mistaken for a perinephritic or lumbar 
abscess. The progress of a discharging empyema is, as has already been 
pointed out, apt to be very chronic, especially if the original cavity were 
large — the discharge then often becoming fetid ; and independence mainly 
on the copiousness of the discharge, the patient becomes emaciated, and 
presents the ordinary symptoms of hectic fever. In many such cases, for- 



/ 



PLEURISY. 



883 



tunately, more or less complete recovery takes place after a time ; this 
event is, on the whole, more frequent when the empyema opens through the 
lung than when it discharges externally — a circumstance which seems to 
depend in some degree on the much greater tendency there is in the latter 
case than in the former to the decomposition of the purulent contents'. In 
many cases, on the other hand, the patient sinks slowly and at length dies 
worn out and exhausted, or he is carried off by sudden intrapleural hemor- 
rhage, or asphyxia. 

It often happens that the communication of an empyema with the bron- 
chial tubes, or directly with the external atmosphere, permits of the 
entrance of air into the pleural sac, and that hence pneumothorax is estab- 
lished. The supervention of this condition may ordinarily be recognized 
by the presence of augmented resonance over the air-containing portion of 
the cavity, of the splashing sound caused by succussion, of cavernous 
resonance, and probably of distinct metallic tinkling. 

In the foregoing account we have discussed the symptoms mainly of 
simple unilateral idiopathic pleurisy ; it may be added that the symptoms 
of the complicated disease are essentially the same, but they are interwoven 
with those of the complicating disorder, and are sometimes masked by 
them ; and further that both pleurae are occasionally implicated, with cor- 
responding aggravation of symptoms. We may also add that pleuritic 
patients, during the period.of effusion, usually lie on or towards the affected 
side ; and also that they much more frequently suffer from cough than 
might perhaps be gathered from the remarks we have made. The cough, 
however, is no necessary part of the disease, and is often due to the pres- 
ence of associated pneumonia or bronchitis. 

Treatment — The treatment of ordinary cases of pleurisy is not usually 
a matter for anxiety. In mild cases of so-called dry pleurisy the applica- 
tion of a mustard plaster or other counter-irritant, the binding of the chest 
with a broad flannel roller or the affected side with strapping to restrain 
its movements, and the use of opiates in small doses will probably be 
sufficient. 

In severer cases, in which there is manifest fever and increasing effu- 
sion, it is often beneficial to apply (according to circumstances) from half 
a dozen to a dozen leeches to the surface of the chest, to follow up their 
application by poultices or flannels wrung out in hot water, and then per- 
haps after a time by counter-irritants. In these cases, even more than in 
the former, opiates are of value, if only to alleviate pain and distress. 
Soda-water, or some other febrifuge medicine, may also be employed. 

If the effusion still increase, and especially if the patient begin to suffer 
from shortness of breath, the arrest of the effusion and the removal of the 
fluid which has already accumulated become the chief indications for treat- 
ment. For these purposes diuretics, diaphoretics, and purgatives have each 
been strongly advocated, and among drugs mercury, antimony, digitalis, 
and iodide of potassium. We believe that all such agents are practically 
useless for the purposes here indicated, and that, if we are to trust in 
drugs at all, they should be those which, by tending to improve the general 
health of the system, tend indirectly to promote healthy action at the seat 
of disease ; we mean tonics, especially iron and quinine. Counter-irri- 
tants, and especially repeated small blisters, sometimes seem to aid absorp- 
tion. The only other means at our disposal for the removal of fluid, and 
this is in many respects by far the best, is paracentesis. This operation 
was formerly greatly dreaded and seldom performed except in cases of 



384 



DISEASES OF THE RESPIRATORY ORGANS. 



empyema already pointing. It is in great measure due to Trousseau, that 
during the last thirty years, paracentesis has come to be recognized as a 
safe and efficacious procedure in cases of excessive accumulation of simple 
serum. More recently, especially since the introduction of suction instru- 
ments, and through the able advocacy of Dr. Bowditch, the use of the 
operation has been still more widely extended. The objects to be attained 
by paracentesis are : first, the removal of pressure from the lung so as to 
permit of its redistension ; second, the prevention of death from suffoca- 
tion ; and, third, the removal of purulent fluid. It is also generally believed 
and perhaps correctly, that the discharge of a certain proportion of fluid 
from a distended cavity promotes the absorption of the rest. 

With the first of the above objects the fluids should be let out early, 
inasmuch as the longer the lung has been compressed and the more firmly 
it is bound down by adhesions the less likely is restoration to take place. 
With the second of these objects the pleura should be punctured either 
when the patient suffers from obvious difficulty of breathing, or when, 
even if dyspnoea seems absent, the cavity is greatly distended. The sus- 
pected presence of pus is always a legitimate ground for operation. In all 
these cases a fine trocar and canula should be employed ; the instrument 
should be plunged into the chest at a suitable point, generally, as recom- 
mended by Dr. Bowditch, an intercostal space directly below the angle of 
the scapula and above the low r er limit of the opposite healthy lung ; and 
the fluid should be removed either by the aspirator, or by a tube guarded 
by a valvular fold of goldbeater's skin, so as to prevent the admission of 
air. The entrance of air, however, though an accident to be avoided as 
involving additional risk, often has no ill effect. It is not generally ad- 
visable to attempt the removal of the whole of the fluid at one time. If 
pus be present it may be taken away by periodical aspiration, or its free 
discharge may be maintained through a permanent opening ; we prefer 
the former, especially in the case of children. For the different methods 
by which at the same time a free escape of pus may be allowed and the 
entrance of air prevented, we must refer to surgical works. It is sufficient 
to say here that, so long as the discharge remains sweet, the entrance of 
air must be carefully guarded against ; but that when it gets fetid, little is 
to be gained by further exclusion of air. It then becomes important to 
w 7 ash out the cavity daily either with pure water or with water medicated 
with quinine, nitric acid, chlorinated soda, or carbolic acid. 

The operation of paracentesis with a very fine trocar and canula, if air 
be excluded, is perfectly harmless. And for this reason, as well as on 
account of the great importance of preventing permanent collapse of the 
lung, we strongly uphold the practice of the early, and if necessary, re- 
peated removal of pleuritic fluid. Again, it is of little practical importance 
if in attempting paracentesis we wound the lung, kidney or other neigh- 
boring organs, and hence, although we recommend caution, we advocate 
early exploratory puncture when there is reason to suspect the presence of 
circumscribed accumulations of pus. 

In the treatment of chronic pleurisy, or empyema, and during the whole 
period of convalescence, the importance of tonics, good diet, and change 
of air cannot be over-estimated. 



CIRRHOSIS. 



385 



VI. CIRRHOSIS. {Chronic pneumonia. Fibroid phthisis.) 

Definition A distinction is not unfrequently made between cirrhosis 

and chronic inflammation of the lungs. It is difficult, however, to appre- 
ciate in what the difference consists ; and we prefer, therefore, to regard 
the two conditions as identical. We mean by these expressions induration 
of the lung, by the development of nucleated fibroid tissue, either around 
the bronchial tubes, or in the interlobular septa, or in the walls of the air- 
cells, or in all these situations at once, and the consequent gradual efface- 
ment of the air-cells. 

Causation There is reason to believe that cirrhosis is an occasional 

result of ordinary acute pneumonia; it is far more frequently, however, a 
sequel of catarrhal or lobular pneumonia, and of chronic pleurisy with 
effusion. A not uncommon cause is the habitual inhalation of solid parti- 
cles, such as those of coal-dust, mill-stone grit, copper ore, flax-dust, and 
the like, by those whose occupations expose them to the danger of such 
inhalations. It is certain that it occasionally ensues on simple chronic 
bronchitis and on the retrogression of both gray and caseous tubercular 
deposits. The question how far, in some cases, it is to be regarded as the 
result of a constitutional taint, has been often raised. There is no doubt 
that we occasionally meet with a similar condition simultaneously involving 
several organs — more especially the lungs, liver, and kidneys — a fact which 
is certainly entitled to some weight on the affirmative side of the question. 
But, on the other hand, it must be remarked that hepatic cirrhosis is trace- 
able, in the great majority of cases, to the influence of alcoholic irritation 
of the matrix of the liver, and that pulmonary cirrhosis (independent of 
tuberculosis) is usually limited exclusively to one or other lung — facts 
which are at least as weighty on the opposite side. 

Morbid anatomy — Cirrhosis of the lung consists essentially in the 
gradual invasion of the solid tissues of the organ by a nucleated fibroid 
growth. This, on the one hand, surrounds and involves the bronchial 
tubes (especially the smaller ones) and the vessels which accompany them ; 
on the other hand, invests the lung itself (which is then usually strongly 
adherent to the parietes) and separates its lobes from one another; and 
from both sides is prolonged into the inter-lobular septa, so as to divide 
the lung-tissue by bands of fibroid tissue of different degrees of density, 
thickness, and visibility, into a series of polygonal islets. With the further 
progress of the disease, the same kind of thickening takes place irregularly 
in the walls of the air-cells, so that before long the cut surface presents a 
coarse retiform arrangement of dense fibroid tissue ; and this, gradually 
increasing, finally renders the whole organ, or portions of it, uniformly 
dense, hard, and airless. It must be observed that, although in cirrhosis 
there are usually both induration of the tissues around the bronchial tubes 
and dense adhesions between the opposed pleural surfaces, it often happens 
that the most obvious, if not the primary, change is that which pervades 
the ultimate tissue of the lungs. It need scarcely be said that this is 
necessarily the most important. 

Accompanying the interstitial growth of fibroid tissue, there is usually 
a more or less abundant deposit of black pigment in irregular patches. 
This is natural in the lungs of persons advanced in age; but in cirrhosis 
it is often, if not always, excessive. The pigment is seated in the thick- 
ened walls of the air-cells and especially in the connective tissue which 
25 



386 



DISEASES OF THE RESPIRATORY ORGANS. 



surrounds the bronchial tubes and vessels, and separates lobules from one 
another. It is always abundant also in the bronchial glands. It may often 
be found distinctly contained in the connective-tissue corpuscles, and taking 
the course of the lymphatic vessels. There is good reason to believe that 
it is to a large extent carbonaceous matter of extraneous origin, which has 
been inhaled into the lungs, has been absorbed by the mucous surface of 
the respiratory tract, and has then got deposited in the tissues and taken 
up by the lymphatics. The presence of pigment usually gives a peculiar 
mottled aspect to the sectional surface of the cirrhosed lung ; but if in great 
abundance, it renders the tissues uniformly and intensely black. 

The ultimate effect of cirrhosis of the lung, like that of the same condi- 
tion in the liver, although it may perhaps under some circumstances cause 
temporary enlargement, is to produce gradual contraction and diminution 
of the organ. The progress of the disease is further always complicated 
with dilatation and other changes in the bronchial tubes, and not unfre- 
quently with equivalent affections of the air-cells. The larger tubes are 
generally more or less considerably dilated, the fibroid and muscular t>ands 
which mark their mucous surface with longitudinal and transverse ridges 
are hypertrophied and produce a coarsely reticulated appearance, and the 
mucous membrane itself is probably congested and thickened. The chief 
changes, however, occur in connection with the smaller tubes, which in 
some cases are dilated into bulb-ended channels ; sometimes terminate in 
round or sub- globular cystiform expansions, from the size of a cherry to 
that of a small pea ; sometimes open (several of them in common) into 
cysts or cavities of large size and irregular form ; sometimes are continued 
into recently-formed and progressing cavities, which, when small, may 
easily be recognized as originating in the ulcerative destruction of the walls 
of the smaller tubes and air-passages. The mode of origin of dilated tubes 
in this and other pathological conditions will be considered hereafter. It 
will be sufficient to say here, that, in many cases, so-called ' dilated tubes' 
are merely tubes in communication with cavities whose walls have under- 
gone cicatrization ; that there is (as might be supposed) a strong tendency 
for the adventitious fibroid growth of cirrhosis to undergo liquefaction 
under the influence of inflammatory processes commencing at the bronchial 
surface ; and that the formation not only of vomicae, but probably also of 
many dilated tubes, are referable to such liquefaction. Ordinarily in cir- 
rhosis the air-cells undergo gradual obliteration, their diminishing cavities 
being sometimes filled with disintegrating epithelial and other cells ; but 
not unfrequently more or less emphysema is developed at the same time. 
When cirrhosis is limited to some comparatively small tract of lung, em- 
physema is common in the tissue which immediately bounds the indurated 
patch. Occasionally, also, the formation of a dense fibrous reticulum 
throughout the lung is associated to a greater or less extent with the 
breaking down of the thickened walls of dilated air-cells, so that the cut 
surface of the lung becomes not altogether unlike that of a coarse sponge. 
We have an impression that the condition last described may ensue on the 
retrogression of a crop of miliary tubercles. 

Cirrhotic lungs present very great variety of appearance and character; 
at the same time it is easy to see that, however much they may differ from 
one another in the stage of the disease which they have reached, in the 
amount of pigment which is present in them, in the condition of their 
bronchial tubes, and in the tendency to the formation of vomicae, they are 
all linked together by the community of their origin in simple fibroid over- 



CIRRHOSIS. 



387 



growth. The following are some of the varieties of cirrhosis which have 
been described and named : — Red induration, the name given to an early 
or slight condition of the disease, in which the lung is of large size, red, 
and fleshy, and, although denser than natural, and infiltrated to some ex- 
tent with adventitious growth, is still generally crepitant ; brown indura- 
tion, the name employed to designate a condition of lung in which the 
capillaries are dilated and thickened, and in which the color of the organ 
has a yellowish-brown tint, and the fluid exuding on pressure is similarly 
colored, in consequence of the presence in the tissues of the lung of the 
coloring matter of the blood in the form of pigment-granules ; brown in- 
duration is especially an accompaniment of heart disease ; gray indura- 
tion, the name which is sometimes applied to the condition of the lung in 
advanced cirrhosis, when the organ is extensively infiltrated with fibroid 
matter and presents in consequence a general grayish tint and a more or 
less translucent aspect ; black induration, which is sometimes used as the 
designation of that form of cirrhosis in which the cirrhotic tissue is largely 
infiltrated with black pigment, and of which the most striking examples 
are furnished by the lungs of persons working in mines or otherwise exposed 
to the inhalation of soot or other carbonaceous matters. It may be added 
that the pulmonary affections which are so frequently the causes of death 
amongst those who are engaged in certain avocations, as, for example, 
amongst miners, colliers, flax-dressers, millstone grinders, and the like, 
and which are commonly known as the phthisis of those who are thus 
respectively engaged, are mostly, as has already been indicated, of the 
nature of cirrhosis. They originate in the bronchitis which is caused and 
maintained by the constant inhalation of solid particles; of which many 
get deposited in the solid tissue of the lungs, and remain there perma- 
nently. The fibroid infiltration slowly supervenes. It appears from Dr. 
Greenhow's investigations that the nature of the dust inhaled does not 
exert any specific influence over the morbid changes which ensue. The 
nature of the imbedded particles can generally, however, be pretty readily 
recognized w T ith the aid either of the microscope or of chemical reagents. 

Symptoms — The symptoms of cirrhosis of the lungs, apart from those 
of the numerous conditions which complicate it, and from those of the 
morbid conditions out of which it may have arisen, scarcely admit of 
description or recognition. The disease is one the progress of which is 
exceedingly chronic, and may be prolonged for five, ten, or even fifteen 
years. 

It is easy to see that, if any large extent of lung-tissue be involved, 
the patient must suffer from progressive breathlessness ; that from the ob- 
struction which the indurated and contracted lung-tissue opposes to the 
pulmonic circulation, hypertrophy and dilatation of the right side of the 
heart must ensue, to be followed sooner or later by general anasarca ; that 
there must gradually supervene impairment of nutrition, failure of the 
general powers of the body, weakness and emaciation ; that the pulmonary 
changes must result in impairment of thoracic movement with retraction 
of the thoracic parietes, more or less obvious dulness on percussion, and 
either suppression of the respiratory sounds, tubular breathing, or (if there 
be secretion into the tubes) the various unnatural sounds which bronchial 
accumulation is competent to induce. Generally, moreover, there are pre- 
sent (at all events at some stage or other of the affection) more or less 
bronchitis with secretion, more or less dilatation of the tubes or air-cells, 
more or less breaking down of tissue with the formation of vomicae, and 



388 



DISEASES OF THE RESPIRATORY ORGANS. 



more or less distinct inflammatory action ; and the symptoms of these con- 
ditions must be added in order to have a true picture of the symptomatic 
phenomena of cirrhosis of the lungs. 

Briefly, then, it may be stated that a patient with cirrhosis presents the 
following symptoms variously combined: — He has more or less obvious 
dyspnoea, especially on exertion, which gradually increases upon him, and 
is generally aggravated during the winter months, or by the occurrence of 
catarrh or pulmonary inflammation. Pallor and lividity of surface, with 
congestion of the nose, fingers, and toes, often supervene sooner or later. 
Cough is almost always present in a greater or less degree, and in some 
cases is very severe ; it may, however, be wholly absent, especially during 
warm weather. It may or may not be attended with expectoration ; but 
expectoration is often profuse, especially when the cirrhosis is complicated 
with dilated tubes or vomicae, and generally muco-purulent or purulent. 
Under the same circumstances it is liable to be extremely fetid, and, in 
the case of colliers and others, almost black from the presence of pigment- 
particles. Haemoptysis is not unfrequent. In many cases the sputa are 
merely streaked with blood as in ordinary chronic bronchitis; in some 
cases, however, more or less profuse hemorrhage occurs from time to time. 
This is due sometimes to perforation of bloodvessels in the course of de- 
structive, changes, sometimes to intense hyperaemia (probably of inflamma- 
tory origin) of the lining membrane of the dilated tubes. The auscultatory 
and percussive phenomena will be considerably modified according as di- 
lated tubes or cavities are absent or present, and according as these are 
full or empty of fluid. The pulse may at first present little departure from 
the normal, but as the disease progresses it tends to become rapid and 
weak, and sometimes irregular; and at the same time, as has been pointed 
out, general anasarca may ensue. Elevation of temperature and other 
febrile symptoms are very variable in their occurrence. Not unfrequently, 
at certain periods of the affection, there is a total absence of them. But 
much more commonly the patient presents more or less of the usual symp- 
toms of hectic fever: some degree of elevation of temperature, which, 
however, is liable to fluctuations; perspirations; loss of appetite; some- 
times vomiting and diarrhoea ; and gradually increasing emaciation and 
debility. The local and general symptoms and history of cirrhosis not 
unfrequently closely resemble those of retraction of the lung after simple 
pleurisy, or those of chronic bronchitis with emphysema, or those of 
phthisis. 

Treatment — Our principal aims in the treatment of cirrhosis should be, 
by attention to hygiene and diet, to arrest the progress of the morbid pro- 
cess, to prevent the supervention of complications, and to maintain the 
bodily strength. For these purposes change of scene, removal to a mild 
but equable and bracing air in the summer, and to a warmer southern 
climate in the winter, the avoidance of night air, exposure to sudden chills, 
over-fatigue and the like, the use of good, wholesome, and abundant diet, 
with a. moderate amount of stimulants, and the exhibition of quinine, iron, 
cod-liver oil, or other tonics, are of vital importance. When the cirrhosis 
is due to occupation, the patient should give it up and follow some more 
healthy pursuif. But, in addition, symptoms, as they arise, will neces- 
sarily call for treatment : cough and expectoration may demand opiates 
and expectorants, haemoptysis astringents, shortness of breath diffusible 
stimulants, diarrhoea medicines which check the alvine flux. It is need- 
less, however, to pursue the list of possible complications and to indicate 
the various methods by which they may severally be relieved. 



TUBERCLE. 



389 



VII. TUBERCLE. 

{Laryngeal and pulmonary phthisis. Tubercular pleurisy.*) 

Causation. — The etiology of tuberculosis is a subject of the highest inte- 
rest, and at the same time one of extreme difficulty. There are few affec- 
tions in which the influence of hereditary taint is so strongly shown. It 
is a well-established fact that children of tubercular parents are pre-emi- 
nently liable to tubercular affections, and not only so, but that, if one 
parent be tubercular, the children who most resemble that parent in con- 
formation are usually most prone to be affected ; and, further, that parents, 
themselves seemingly healthy, or at all events free from tubercle, not un- 
frequently beget a family of children who die one after the other of pul- 
monary phthisis. In the case last referred to the tubercular tendency of 
the children may be due either to the transmission of a taint which is 
latent as regards the parent, or to the fact that one or other parent is 
scrofulous or syphilitic, or in some other way impaired in health. But 
tuberculosis does not occur only among those who inherit a tendency to it. 
Climate has certainly some influence in its production ; for it is much 
more frequent in temperate climates than it is in those which are either 
very cold or very hot ; and Dr. Buchanan's and Dr. Bowditch's researches 
seem to prove that in temperate climates it prevails far more extensively 
in low, damp situations than it does in such as are elevated and dry. There 
is no doubt that conditions which produce deterioration of the general 
health tend ultimately to induce tuberculosis : among which may be enu- 
merated, inadequate nourishment, excessive work with insufficient rest, 
and want of fresh air. Hygienic defects of this kind are specially injurious 
to the young. Other causes of tuberculosis are, occupations which neces- 
sitate the inhalation of solid irritating particles (for there is no doubt that 
tuberculosis, as well as cirrhosis, and not unfrequently both in combina- 
tion, are thus produced), and the cachexias which follow or attend upon 
enteric fever, measles, hooping-cough, syphilis, diabetes mellitus, and va- 
rious other diseases. No age is free from liability to tuberculosis ; it is 
extremely common in young children, but, putting these on one side, the 
age of greatest liability is from twenty to thirty or thirty-five. The influ- 
ence of sex is uncertain. 

Morbid anatomy. — 1. Laryngeal tubercle always manifests itself in the 
form of minute gray granulations, which may easily be overlooked, but 
which, nevertheless, present all the microscopical and other characteristics 
of gray tubercles. They are situated in the substance of the mucous mem- 
brane, and tend after a time to form small round shallow ulcers, which by 
their coalescence constitute sinuous, but rarely extensive tracts of ulcera- 
tion. It is very common, in the course of pulmonary phthisis, for the 
larynx to get implicated; but to what extent this implication, in many 
cases, is due to actual tuberculosis of the larynx is a matter of considerable 
doubt. The mucous membrane becomes congested, (edematous, and thick- 
ened, and excoriations appear, which sooner or later extend deeply, expos- 
ing the cartilages, and causing their erosion. These deep ulcers are most 
commonly situated towards the posterior extremities of the vocal cords, and 
involve the anterior processes of the arytenoid cartilages. All the carti- 
lages, however, are liable to be thus affected. 

The trachea and bronchi are subject to the same pathological changes as 
the larynx: their mucous membrane gets congested and thickened, excori- 



390 



DISEASES OF THE RESPIRATORY ORGANS. 



ations manifest themselves with or without the pre-existence of miliary 
tubercles, and occasionally the cartilaginous rings become exposed and 
eroded, and even detached and expectorated. 

2. Pulmonary tubercle — Those who deny the identity between gray 
and yellow tubercles will, equally with those who maintain the opposite 
thesis, admit that the two varieties often coexist in the same individual ; 
and, on the other hand, those who believe in their identity will, equally 
with their opponents, acknowledge that cases of tuberculosis are not 
unfrequently met with which are apparently characterized by the exclu- 
sive presence of one or other form. It will be convenient, therefore, 
while acknowledging their tendency to pass the one into the other, to 
describe them independently, as we not unfrequently meet with them in 
typical cases. 

Gray tubercles vary in bulk from mere points up to the size of a small 
pea. but do not usually exceed that of a pin's head ; they are gray, some- 
what hard, and slightly translucent ; they are sometimes sparsely scattered, 
sometimes closely set, in some cases distributed with tolerable uniformity, 
in others forming scattered groups or clusters of various sizes. In the last 
case, those in the central part of a group coalesce, to a greater or less ex- 
tent, and form tracts individually as large as a marble or walnut. The 
development of gray tubercles is occasionally limited to one lung ; more 
frequently it comprises both, and may then involve them equally or un- 
equally. They are in some cases distributed throughout the whole organ, 
in some limited to certain regions, generally the apex; and, for the most 
part, even when universally distributed, they are most numerous and ad- 
vanced in the upper part of the lung. The growth of miliary tubercles is 
always, in a greater or less degree, associated with other morbid conditions 
of the lung; these are especially congestion and oedema of the pulmonary 
tissue, consolidation of the intermediate tracts of lung, and bronchial 
catarrh mainly implicating the minuter tubules. As regards the consoli- 
dation, it must be observed that this may be of the nature of ordinary pneu- 
monia, with impaction of the air-cells with corpuscular elements ; or of the 
nature of cirrhosis, with fibroid thickening of the walls of the air-cells and 
of the other connective tissues of the lung. A later change is the breaking- 
down of the consolidated bits of lung and the formation of vomicae. Such 
cavities usually commence at the apex, and may be limited to that part. 
They may vary from the size of a pea up to that of an orange or beyond, 
and may present every variety of form. They are usually surrounded with 
a greater or less thickness of indurated tissue, and often present abrupt 
well-defined margins. 

For the most part, miliary tubercles are developed with great rapidity, 
and tend to a rapidly fatal issue. Occasionally, however, their progress 
is arrested, and the patient recovers, but with more or less permanent damage 
to the tissue of lung. "When this happens in respect of discrete tubercles, 
the organ gets seamed throughout with minute patches of cicatricial tissue 
the fibres of which have something of a stellate arrangement, and within 
the limits of which the lung-tissue presents, from the presence of concur- 
rent emphysema, a coarsely spongy character ; and occasionally in the 
centre of the scars minute fibroid knots or concretions may be recognized. 
When the affection becomes arrested after groups of tubercles have got 
consolidated by the intervention of inflammatory overgrowth, more or 
less extensive tracts of tissue, probably studded with cretaceous or case- 
ous masses and black pigment, assume a cirrhotic character, and con- 



TUBERCLE. 



391 



tract, while usually more or less emphysema arises in their immediate 
neighborhood. Further, when cavities have formed, they either shrink 
and become lined with a definite smooth membrane, continuous with that 
of the bronchial tubes, or possibly, in rare cases, get obliterated. 

Yellow tubercles in process of development present an opaque, yellowish - 
white, slightly granular character. They are peculiarly dry and friable, 
furnishing no juice, but readily yielding, on being scraped or squeezed, a 
pulpy detritus. They are usually of larger size than gray tubercles, and 
present, for the most part, a well-defined outline and more or less irregular 
form. They evidently comprise groups of air-cells or lobules, and are 
hence polygonal when cut across ; but when divided in the direction of 
the bronchial tubes, are found to involve the minuter branches of these 
and to be arranged upon them in a lobulated or foliaceous manner. In 
their early stage, a cross-section will probably have the size of a split tare 
or pea ; they soon, however, partly by individual growth, partly by coales- 
cence, assume larger dimensions. Occasionally, as the result of such coa- 
lescence, large tracts of lung-tissue, possibly the whole of a lobe, become uni- 
formly infiltrated — a condition to which, in the nomenclature of the College 
of Physicians, the name of ' chronic pneumonic phthisis' has been given. 

Yellow, like gray tubercles, usually commence at the apex of a lung, 
sometimes at the apex of the lower lobe, and gradually spread thence 
downwards. They are usually, too, more advanced at the apex than else- 
where. It must not be forgotten, however, that they may originate and 
attain their most advanced stage in any part of the lung. The tendency 
of yellow tubercles to undergo liquefaction is far more marked than that 
of gray tubercles ; so that, although a lung may become very largely in- 
volved without breaking down, in the great majority of cases softening 
takes place both early and extensively. In one case of rapid phthisis 
which came under our notice, destructive softening must have been almost 
coetaneous with the development of the tubercles, for though both lungs 
were thickly studded with cheesy masses, there was scarcely one of them 
which was not almost wholly converted into a flocculent-walled cavity. 
The lungs, indeed, were lighter than natural, and appeared at the first 
glance to have large air-containing bullaa thickly disseminated throughout 
their substance. The vomicae of this form of phthisis usually originate in 
the upper parts of the lungs, and there attain their chief development. 
They commence with the liquefaction of those portions of the masses which 
immediately bound the bronchial passages and smaller tubules; so that, in 
the first instance, though roundish when cut transversely, they present a 
dendritic form when the incision takes the course of these channels. A 
cavity once commenced increases more or less rapidly in size, and ere long, 
by coalescence with neighboring cavities, may assume gigantic proportions. 
It may even occupy the whole of a lobe. Large cavities are usually more 
or less anfractuous in form, and often crossed by bands of condensed tis- 
sue, comprising vessels (mostly impervious) of considerable size. Cavities 
in process of formation present more or less ragged parietes ; but when 
they have ceased (as they often do cease) to enlarge, their surfaces get 
smooth, and even polished, and the tissues round them more or less indu- 
rated. Yellow tubercle not unfrequently undergoes retrogressive changes. 
These consist in it's gradual conversion, first, into a mortary, and lastly, into 
a calcareous inert mass, encapsuled by a dense fibroid envelope. The con- 
traction of cavities, the calcareous conversion of tubercular masses, and 
the induration of the tissues around, are always attended with diminution 



392 



DISEASES OF THE RESPIRATORY ORGANS. 



in the bulk of the affected portions of lung, and compensatory expansion 
or displacement of the neighboring healthier tissues. 

In both forms of tuberculosis, it sometimes happens that gangrene takes 
place ; or that profuse hemorrhage occurs either from intensely congested 
surfaces or from perforation occasionally preceded by aneurismal dilatation 
of an artery ; or that the tubercular vomica, like any other abscess within 
the chest, opens into the pleura, or through the outer thoracic walls, or 
perforates the diaphragm. 

3. Pleural tubercle differs in no important respect from tubercle of other 
serous membranes. It appears almost invariably in the form of minute 
grayish spots variously arranged, sometimes occupying the serous mem- 
brane itself, sometimes apparently imbedded in the substance of recently- 
formed false membranes. These bodies may be scattered over the whole 
surface, or limited to certain spots ; and are generally, even when widely 
spread, most thickly congregated in certain regions where it may be pre- 
sumed they originated. They are often specially numerous between the 
lobes and upon the diaphragm. When very abundant they touch one 
another, or coalesce so as to form extensive tracts. When this takes place 
the opposed pleural surfaces are usually adherent, and the tubercular 
laminae appear to occupy the substance, of the intervening false membrane. 
As the tubercles increase in size and run together they assume an opaque 
buff color and become friable, resembling in look and consistence cheesy 
masses in the lungs. Pleural tubercle is, in the great majority of cases, 
associated with tubercle of other organs; occasionally, however, it is prim- 
ary in the pleurae, and may even be limited to one. It is very commonly 
associated with tubercle of other serous membranes; and, as might be sup- 
posed, is usually coincident with some amount of similar disease in the 
lungs. It is nevertheless a fact that it is by no means a frequent compli- 
cation of pulmonary phthisis, notwithstanding that pleuritic inflammation 
is an invariable attendant on that affection. Tubercle of the pleura is not 
necessarily accompanied with inflammation of that membrane ; in most 
cases, however, sooner or later, and sometimes from the very commence- 
ment, inflammation takes place, and the usual phenomena of pleurisy then 
combine with those of tuberculosis, — false membrane is formed, effusion 
takes place, perhaps suppuration ensues, and indeed any one or all of the 
.various events which have been already fully considered under the head 
of pleurisy are apt to supervene. 

It would be out of place here to enter at any length upon the associated 
morbid anatomy of tubercular affections of the respiratory organs, which, 
however, plays so important a part in the progress and symptoms of ordi- 
nary cases of pulmonary phthisis. It will be sufficient to draw attention 
to the fact, that tubercles are rarely limited to these organs, and that their 
simultaneous development in other organs may induce consequences of 
much more urgent gravity than those referable to the laryngeal, pulmonary, 
or pleural affection. Among the more important complications of pulmon- 
ary phthisis are inflammation of the lungs and pleurae, tubercular menin- 
gitis, tubercular peritonitis, and tubercular ulceration of the intestine, to 
which may be added fatty and lardaceous degenerations of various organs. 

[Although the fact that many excellent observers teach that all the lesions 
of pulmonary phthisis are distinctly traceable to inflammatory processes 
has been incidentally alluded to in the earlier part of this work, it seems 
only proper that it should be more fully referred to in this connection. 
This view has been held since the time of the distinguished Addison, who, 



TUBERCLE. 



393 



in 1845, expressed the opinion that "inflammation constitutes the great 
instrument of destruction in every form of phthisis," by a large number of 
both practical physicians and microscopists of eminence, and has recently 
been very ably maintained by Dr. T. Henry Green, of London, whose right 
to speak with authority in questions of pathology will scarcely be denied. 
This gentleman holds that there is nothing peculiar in the histological 
changes in the lungs in phthisis, and that these are all met with in condi- 
tions which do not come within this category and which are confessedly 
inflammatory in character. In catarrhal pneumonia there is an accumu- 
lation of fibrin, leucocytes and epithelial cells in the alveoli in varying 
proportions just as there is in acute phthisis. If the process has been a 
more prolonged one the walls of the alveoli and of the terminal bron- 
chioles are found in both of these conditions also infiltrated with small 
cells, and if it is still more chronic there is in addition to these changes, 
in greater or less degree, depending upon the length of time the disease 
has lasted an increased development of the interlobular connective tissue. 
Even the giant cells which are regarded by many as characteristic of 
phthisis are really identical with the large cells found in scrofulous inflam- 
mation and are, in his opinion, the result of an inflammatory process of 
slight intensity occurring in tissues of such low vitality that the cellular 
products are incapable of forming an organized tissue, but merely undergo 
some increase in size and then tend to slowly degenerate. In the early 
stages of phthisis the changes in the lung would then appear to be a filling 
up of the alveoli with epithelial cells and a moderate amount of infiltration 
of their walls with small cells. This often takes place, as has been said, in 
catarrhal pneumonia, and in a perfectly healthy and vigorous person is a 
condition from which recovery is not only possible but probable. It is 
otherwise, however, in one predisposed to consumption, in whom the pro- 
ducts of inflammation are very apt to undergo caseous degeneration, and, 
by pressure upon the bloodvessels and thus cutting off or diminishing the 
supply of blood, to interfere with the due nutrition of the lung. Hence 
softening and breaking down of the lung, with the formation of cavities 
take place. From a clinical standpoint the evidence in favor of the in- 
flammatory origin of phthisis is in many cases even more convincing. In 
a large number of instances,' the patient is able to trace his illness to a 
definite exposure — to a chill or a wetting which has been followed by an 
attack of pneumonia or bronchitis, from which he has never fully recovered 
his health. In others, the starting point of the disease has been an attack 
of measles, typhoid fever, or hooping-cough, upon all of which bronchitis 
is an almost constant attendant. Phthisis cannot be said to be here wholly 
the result of the debility left by these diseases, for it does not occur as a 
sequel of other diseases of equal severity, but not having this tendency to 
pulmonary complications. A careful analysis of the physical signs of 
phthisis will show that they are as intelligible under this view as under 
that adopted by the author.] 

Symptoms and progress — So much attention has been devoted to the 
symptomatology of pulmonary phthisis, so much has been written on this 
subject, and so elaborate are the details with which we have been furnished, 
that it seems at first sight an almost hopeless task to endeavor to compress 
our description of the symptoms of the disease within reasonable limits. 
When, however, we bear in mind that, in most of the elaborate accounts 
to which we refer, the symptoms of pulmonary phthisis are made to include 
the symptoms due to tuberculosis of all other organs, those referable to the 



394 



DISEASES OF THE RESPIRATORY ORGANS. 



many complications which are apt to supervene in the course of phthisis, 
and besides these the symptoms of the various forms of ill-health which so 
often precede phthisis, it will be seen that the symptomatology of the pul- 
monary affection has been overlaid with an abundance of matter which, 
however important, does not immediately concern us now. The following 
description will be limited almost exclusively to the symptoms which are 
referable to the affections of the respiratory organs themselves. 

In a large number of cases the invasion of pulmonary phthisis is re- 
markably insidious. A patient who has previously, it may be, enjoyed 
robust health, slowly and without obvious cause becomes weak and thin, 
probably suffering at the same time from slight remittent febrile symp- 
toms ; or, possibly after exposure to the causes of catarrh, he becomes the 
subject of dry irritating cough which he cannot shake off, and ere long 
experiences loss of flesh and strength ; or he suffers in the first instance 
from slight symptoms of laryngeal inflammation, which slowly increase in 
severity ; or, without previous warning, he has a sudden and profuse attack 
of haemoptysis, on the subsidence of which some of the various symptoms 
above considered supervene ; or a patient, subsequent to an attack of fever, 
or pneumonia, or in the course of some wasting disease, is attacked with 
cough, and the symptoms of phthisis gradually replace those of the pri- 
mary malady. The frequent occurrence of gradual deterioration of health, 
without the presence of any specific symptoms of disease, prior to the ob- 
vious development of pulmonary phthisis, has induced many physicians to 
believe in the existence of a stage of phthisis antecedent to that of tuber- 
cular deposition — a belief, however, based on utterly insufficient data. 

But in whatever way phthisis first manifests itself, the symptoms of the 
fully-developed disease ere long become established. These consist mainly 
in cough, attended with more or less abundant muco purulent expectora- 
tion, and occasional or frequent haemoptysis; hectic fever, marked by more 
or less regularly periodical febrile exacerbations, profuse perspirations, 
especially at night time, rapid emaciation and loss of strength ; and the 
local evidences, on percussion and auscultation, of progressive involvement 
and destruction of lung-tissue. 

We proceed to discuss the various symptomatic phenomena of phthisis 
seriatim. In a certain number of cases the symptoms of which the patient 
first complains are referred to the larynx; and it may be that throughout 
the whole course of the affection the laryngeal symptoms continue chiefly 
distressing to him. These differ scarcely at all from those of ordinary 
chronic laryngitis except in their obstinacy and progressive character, and 
in the gradual supervention of emaciation and loss of strength, and of indi- 
cations of advancing pulmonary disease. In a still larger number of cases, 
and indeed in a very large proportion of the entire number of cases of 
phthisis, laryngeal symptoms of a more or less severe character come on 
sooner or later in the course of the pulmonary disease. These are some- 
times simply irritative or catarrhal, and subside ; but more frequently they 
resemble in all respects, inclusive of their causation and progress, those of 
the earlier laryngeal affection. It is a question which can scarcely be said 
to be even now clearly decided, whether laryngeal phthisis (as it is termed) 
ever actually precedes the pulmonary disease. The general belief is that 
it is always secondary, and there is no doubt that at post-mortem exami- 
nations laryngeal phthisis is never found unassociated with tubercles in 
the lungs. The laryngoscopic characters of laryngeal phthisis have been 
described under the head of chronic laryngitis. 



TUBERCLE. 



395 



The presence of cough is one of the most constant and striking pheno- 
mena of phthisis. It generally begins early, and increases in frequency 
and severity with the progress of the disease. In the beginning it is usu- 
ally short and hacking, and either dry or attended with scanty glairy 
expectoration. It is probably then due to slight bronchial irritation only, 
and the discharge consists of bronchial mucus. With the advance of the 
disease and the breaking down of the pulmonary tissue, the sputa usually 
become increased in quantity — often very pro 'use — and at the same time 
opaque, yellowish or greenish, and purulent, often nummulated, sometimes 
fetid. The expectoration is not necessarily distinguishable from that of 
bronchitis. It is furnished partly by the inflamed bronchial tubes, partly 
by the tubercular vomicae ; and sometimes, by careful microscopic exami- 
nation, pulmonary tissue maybe detected in it. The cough has no special 
characteristics by which it may be distinguished from that of bronchitis, 
or (if the larynx be affected) from that of laryngitis. It presents, how- 
ever, considerable differences in different cases; in some it is scarcely a 
matter of complaint from first to last ; in some (especially chronic cases) 
it presents periodical variations, increasing, for example, in the winter or 
cold weather, subsiding in the summer time ; but in the majority of cases 
it is a serious and increasing cause of distress. 

Haemoptysis is one of the commonest accidents of pulmonary phthisis. 
It occurs at some period or other in the course of the great majority of 
cases. Sometimes it is the first indication of the disease ; more frequently 
it comes on at a later period. It may be only sufficient to tinge or streak 
the expectoration, or it may be limited to an occasional succession of san- 
guinolent sputa, or, again, it may be sudden and profuse — the patient 
bringing up in a very short time half a pint, a pint, or even a larger quan- 
tity of blood. It may be so profuse, indeed, at any stage of the disease 
that the patient is suddenly carried off either by choking or syncope. But 
these sudden and profuse hemorrhages are usually among the earliest 
symptoms of phthisis. 

Difficulty of breathing is a common but not necessary phenomenon. It 
may be severe if the larynx be largely affected, or if there be much accu- 
mulation in the bronchial tubes, or effusion into the plurae. In most cases, 
however, the patient makes little or no complaint on this score ; he no 
doubt readily loses wind on even slight exertion, and habitually, perhaps, 
the respirations are more or less augmented in frequency ; but when he is 
at rest his breathing does not usually trouble him. 

The patient often suffers from stich or burning or other kinds of pain in 
the chest. This may occur on one or both sides, often at one apex, but is 
not limited to any one part. Pain is by no means always present; some 
patients never experience it; others suffer from it occasionally only ; in 
some cases it is pretty constant and severe. It is usually augmented by 
movement of the chest, and especially by deep breathing or coughing. It 
is mostly due to pleuritic complication. 

The physical signs of pulmonary phthisis are such as would naturally 
arise from progressive consolidation and contraction of the lung, the for- 
mation of cavities, the accumulation of secretion in them and in the bron- 
chial tubes, and pleuritic inflammation and exudation. In considering 
the significance of the physical signs we must never forget that, as a rule, 
tuberculosis commences at one or both apices of the lungs, that excavation 
usually first takes place in the same situation, and that the morbid pro- 
cesses tend to travel downwards. 



396 



DISEASES OF THE RESPIRATORY ORGANS. 



The presence of small discrete tubercles in the lungs, even if they be 
very numerous and close-set, does not necessarily affect the character of 
the percussion note or the sounds which may be heard on auscultation. 
We can, therefore, readily understand that pulmonary tuberculosis may 
have made considerable progress before giving distinct local indications of 
its presence ; and we must not too readily assume, because we hear nothing 
amiss, that therefore the patient is free from tubercle, or that he is in the 
so-called 4 pre-tubercular stage.' Generally, however, even if there be no 
dulness, there are no bronchitic signs — ronchus, crepitation and the like — 
and these are probably most marked over the upper parts of one or both 
lungs ; or pleuritic friction, or jerky respiratory sounds, which have some- 
times been attributed to the presence of circumscribed patches of pleuritic 
inflammation, may be audible in the same situation. When, however, 
tubercles have coalesced into masses, say from the size of a walnut up- 
wards, and abut upon the surface, their presence materially affects the 
quality of the percussion note over the area to which they correspond. 
There is then more or less marked dulness on percussion, the extent and 
completeness of which are determined by the extent and bulk of the con- 
solidated tract. Dulness from tubercular disease is generally indicated by 
the facts ; that it occurs mainly at the apex in front or behind ; that it is 
rarely equal in these situations, and still more rarely equal in the corre- 
sponding points of both apices ; and that it tends gradually to extend from 
above downwards so as to involve more and more the tissue of the lung. 
In association with dulness there is usually increased sense of resistance on 
percussion, increase of vocal fremitus, diminished movement during respi- 
ration, and more or less obvious flattening. The latter condition is espe- 
cially noticeable when it occurs beneath the clavicle. The auscultatory 
phenomena at this stage are mainly those which attend the second stage of 
pneumonia — tubular breathing, together with (if the tubes contain secre- 
tion) rhonchus, gurgling, crepitation, or occasional clicking or creaking 
sounds, bronchophony, and probably also pectoriloquy. It need scarcely 
be added that, if the consolidated patch be imbedded in the substance of 
crepitant lung, little or no indication of its presence may reach the ear. 
The phenomena which attend the presence of vomicae are very various and 
by no means always characteristic. The existence of one or several small 
cavities in the midst of consolidated tissue does not obviously modify the 
percussion note due to the consolidation. Large cavities, indeed, sur- 
rounded by a thick layer of condensed lung-tissue, generally yield almost 
absolute dulness. In other cases, however, the formation of a cavity in 
consolidated tissue is attended with the redevelopment of resonance, which 
may become almost normal, or may be high-pitched, or present the char- 
acters of the bruit de pot fe!e. On auscultation over cavities we may 
detect (if they contain fluid) large crepitation and gurgling — sounds which 
may also be heard over the larger bronchial tubes when imbedded in con- 
densed lung-tissue ; or (if they be empty) some modification of tubular 
breathing. Occasionally (and this may be the case in respect of cavities 
no larger than a walnut) we may hear distinct cavernous sounds. Metallic 
tinkling is seldom audible over tubercular cavities. In some cases no 
sounds whatever are produced within a cavity, and all that one hears are 
normal or abnormal respiratory sounds transmitted from the parts beyond. 
Both bronchophony and pectoriloquy may usually be recognized ; pecto- 
riloquy, however, is on the whole more marked here than over solid lung, 
bronchophony perhaps less marked. 



TUBERCLE. 



397 



In delicate patients in whom no obvious consolidation can be recognized, 
the persistent presence, at one or other apex, of harsh and prolonged expi- 
ratory murmur, of a few clicking sounds, of rhonchus, of crepitation, or 
of jerky respiration, is ground for the gravest suspicion. By some physi- 
cians, moreover, a systolic murmur over the pulmonary artery and its 
main branches, or in the course of the subclavian artery within the chest, 
is equally regarded as an indication of the presence of tubercular consolida- 
tion — the belief being that the murmurs are produced by the pressure of 
consolidated tissue upon the vessels in question. They are probably 
anaemic. 

The state and action of the circulatory organs are for the most part such 
as we meet with in all chronic diseases attended with progressive debility 
and emaciation. In the earlier stages of phthisis the pulse is usually in- 
creased in frequency and hardness ; with the advance of the disease its 
frequency becomes augmented, but there is diminution of fulness and force. 
With increasing enfeeblement of the circulation it is not uncommon for 
some degree of anasarca to supervene, especially if the enfeeblement of the 
left side of the heart be associated, as it occasionally is, with hypertrophy 
and dilatation of the right side. As a rule, however, the heart undergoes 
general atrophy. In many cases the anasarca is limited to the lower ex- 
tremities, and is then often due immediately to thrombosis of the iliac 
veins. It is doubtless owing to the same enfeeblement of the circulation 
that various parts, and more especially the nose, ears, fingers, and toes, 
frequently get congested, livid, and tumid. A clubbed condition of the 
fingers and toes (although by no means confined to phthisis) is, as is well 
known, of common occurrence in the chronic form of the disease. Each 
ungual phalanx becomes swollen and bulbous, and at the same time more 
or iess congested ; and in consequence of the grape-like form which it as- 
sumes the nail, which occupies the upper half only, becomes bent over the 
summit, forming a kind of sloping roof. 

The symptoms referable to the stomach and bowels are generally of 
considerable importance. The tongue maybe clean throughout the greater 
part of the patient's illness ; it is often morbidly red, however, and often 
more or less furred, and towards the fatal termination is apt to get dry, 
glazed, and fissured or aphthous. There is usually more or less thirst. 
The condition of the appetite presents great variety. In some cases the 
patient has a good, and possibly voracious, appetite; in other cases it is 
capricious ; while in others again there is complete anorexia, and probably 
great irritability of stomach, with gastrodynia, nausea, and sickness. The 
latter conditions depend in some cases on catarrhal inflammation of the 
mucous membrane of the stomach, and are often associated with thinning 
and dilatation of that organ. Phthisical patients are exceedingly liable to 
suffer from diarrhoea, which is often very obstinate and profuse, and often 
assumes a dysenteric character. Persistent diarrhoea indeed, may be the 
most serious of all the morbid conditions from which the patient suffers. 
It is due, in the great majority of cases, to coincident ulceration of the 
bowels — a lesion which complicates fully one-half of the cases of pulmonary 
phthisis, and which may outrun, if it do not precede, the pulmonary dis- 
ease. Diarrhoea may result, however, like the dyspeptic symptoms, 
from mere catarrh, or some other form of irritation of the mucous mem- 
brane. It is a well-recognized fact that tubercular patients are peculiarly 
apt to suffer from fistula in ano. The presence of a fatty liver is seldom 
indicated by symptoms, but may occasionally be recognized by the in- 
creased bulk which the organ attains. 



398 



DISEASES OF THE RESPIRATORY ORGANS. 



The nervous system does not usually present any very characteristic 
morbid phenomena. The patient may be more or less irritable, or, on 
the other hand, apathetic; he is sometimes desponding, but much more fre- 
quently hopeful, buoying himself up even to the last with the prospect of 
eventual recovery. 

Hectic fever and gradual emaciation are by far the most important and 
striking of the general phenomena of phthisis. They commence in most 
cases long before the actual proofs of the growth of tubercles exist, and 
they continue, as a rule, throughout the whole duration of the disease. It 
is important, however, to observe that phthisical patients often undergo 
temporary improvement, that under judicious management they often gain 
flesh and strength, sometimes never lose flesh, and that they not unfre- 
quently remain free from fever for weeks together — sometimes, indeed, 
have scarcely any febrile symptoms during the whole course of their 
illness. 

The hectic of phthisis is almost typical in the distinctness of the daily 
remissions and exacerbations which attend it. There is usually some ele- 
vation of temperature after food, especially after hearty meals, but the 
maximum occurs mostly in the afternoon or evening. The minimum 
temperature in the day may be normal, or even below the normal; the 
maximum may reach anything from 101° to 104° or even 105°. In 
most cases, however, the lowest temperature is still considerably higher 
than natural, and the range less wide than the above figures might seem 
to indicate. Not uncommonly the temperature falls considerably as the 
fatal end approaches. The patient usually suffers during the period of 
exacerbation from heat in the palms and soles, and flushing of the cheeks, 
which is for the most part vivid and circumscribed, and has received the 
name of the 'hectic flush.' Perspiration is a common and distressing 
symptom. The patient complains little of this while he is awake, but 
when he is asleep sweats are apt to break out profusely all over him, ren- 
dering his surface damp and sodden, and his linen and coverings in some 
cases so wet that the moisture may be wrung out of them. These perspi- 
rations are sometimes absent, or they may intermit, or be so slight as to be 
of little significance. 

The emaciation of phthisis is intimately related to the presence of hectic 
fever, both being the consequence mainly of the rapid disintegration of 
the corporeal tissues. All parts of the body, doubtless, waste ; some, 
however (especially the brain and nervous system), less than others. The 
heart dwindles, the bones and muscles become atrophic : but the most ob- 
vious change is in the fat, which gradually and for the most part almost 
entirely disappears. The limbs and trunk consequently shrink, and their 
surface falls into wrinkles ; the skin of the face and forehead becomes 
closely applied to the subjacent bones and muscles, so that the cheek-bones, 
and especially the zygomatic arches, acquire remarkable prominence, and 
the movements of the muscles get painfully visible. The skin itself in 
many cases grows thin and brittle, the nails dry and inclined to split, and 
the hair thin and scanty. In some cases, however, no such changes in the 
cutaneous organs take place, and indeed the hair occasionally presents ex- 
traordinary luxuriance. The extreme emaciation favors the development 
of bed-sores on the buttocks and elsewhere. 

It need scarcely be added that, in a large number of cases of phthisis, 
the presence of complications already adverted to — more especially cere- 
bral, peritoneal, and renal tuberculosis, and degenerative affections of the 



TUBERCLE. 



399 



liver and kidneys — adds other symptoms to those which have been enume- 
rated, and materially modifies the progress of the disease. 

Several varieties of phthisis, which do not necessarily correspond to the 
several varieties recognized by the pathologist, are described by those who 
look at the disease from the clinical point of view. They may be ranged 
under the heads of acute and chronic phthisis. 

The great majority of cases of phthisis belong to the chronic category. 
They commence in one or other of the ways already indicated, and the 
general symptoms and local changes which have been above discussed 
become gradually established. In many cases the disease progresses uni- 
formly, no amendment whatever takes place, and the patient sinks probably 
in from six to twelve months from the first manifestation of symptoms. 
In some cases the duration of the disease is greatly extended : the patient 
suffers from the ordinary symptoms of phthisis, or it may be from those of 
a simple bronchial attack, and then appears to recover more or less com- 
pletely ; but after a while the symptoms recur, and again amendment fol- 
lows ; and again and again, it may be, these alternations of illness and 
comparatively good health take place, until at length the symptoms of the 
disease become continuous, and the patient gradually sinks. In such cases 
the tubercular process probably takes place in successive crops ; and it is 
in them that post mortem we find intermingled, extensive tracts of indurated 
and contracted lung-tissue, encapsuled mortary or cretaceous masses, cavi- 
ties with cicatrized parietes, and emphysema. Tuberculosis dependent on 
the constant inhalation of irritating matters, for the most part takes a 
similar course. Indeed, when phthisis becomes thus chronic, it approaches, 
both in its morbid anatomy and in its symptoms, the lung-affection already 
discussed under the name of cirrhosis. In some cases the progress of the 
disease becomes permanently arrested : and then, in proportion to the ex- 
tent to which the lung-tissue may have undergone disorganization, is the 
restoration to health complete or incomplete. 

In acute phthisis the patient may die in the course of a few weeks, and 
generally dies within three months. Two varieties of acute phthisis may 
be distinguished : first, that in which the tubercles are from the first mainly 
if not entirely yellow, and in which there is very rapid breaking down of 
lung-tissue ; and, second, that in which the tubercles are miliary. The 
first variety resembles the ordinary chronic form of phthisis in its symp- 
toms, excepting only their intensity and the extreme rapidity of their de- 
velopment. It usually begins suddenly with high fever and rigors, and 
pulmonary symptoms which have a close resemblance to those of ordinary 
pneumonia. It is in fact with this disease that it is especially liable to be 
confounded. The second variety also comes on more or less suddenly 
with fever and rigors, and possibly, but not necessarily, some bronchial 
irritation and cough. The symptoms indeed, both at the onset and for 
some time — sometimes throughout the whole course of the disease — have 
a marked resemblance to those of enteric fever with pulmonary complica- 
tion. The state of the pulse, tongue, and cerebral functions may be iden- 
tical in the two affections; in both the bowels may be constipated or loose, 
in both there may be abdominal tenderness and tumefaction ; in both the 
febrile temperature shows marked remissions; in both dyspnoea is apt to 
supervene, and the face to become ghastly or livid. The motions, how- 
ever, are rarely pea-soup-like in the tubercular disease ; the pain in the 
abdomen is less constant, and, if present, is due to peritoneal tuberculosis, 
and therefore less likely to be localized in the csecal region ; the tempera- 



400 



DISEASES OF THE RESPIRATORY ORGANS. 



ture does not present the uniform variations characteristic of enteric fever, 
and there is an absence of the typical typhoid rash. The disease may 
prove fatal without the development of dulness, and without the evidence 
of the formation of cavities. Usually, however, as the disease advances, 
the lungs undergo more or less consolidation, commencing at the apices 
and extending downwards. 

Death in phthisis is due in most cases to asthenia, generally of slow 
development, but sometimes rapid, and immediately referable to extremely 
profuse alvine flux, or to sudden and copious haemoptysis. In some cases 
it may be referred in part or wholly to asphyxia. Such may be the cause 
of death in phthisis associated with laryngeal disease, or much secretion 
into the bronchial tubes, or in which there is sudden effusion of blood into 
the air passages. 

There are no symptoms by which tubercular pleurisy can be distin- 
guished from the simple inflammatory affection, apart from its intractable 
character, and the concurrent or consecutive appearance of tubercles in 
other organs. 

Treatment. — It is of the first importance in the treatment of the early 
stages of phthisis, and indeed in the treatment of all persons in whom a 
tendency to phthisis appears to exist, to adopt every available measure to 
promote the general health, to take every precaution against the infraction 
of hygienic laws. It is obvious, therefore, that many of the details of 
treatment are such as, under the circumstances, common sense would dic- 
tate. We may, however, enumerate a few of the matters here referred to. 
The diet should be wholesome and nutritious, and fairly distributed among 
the recognized meals; the patient should keep good hours, refrain from 
all overwork, whether mental or bodily, clothe himself warmly, and live 
in temperate, well-ventilated, but not draughty rooms. At the same time 
he should not refrain from amusement ; nor need he abstain from business 
or other occupations if they be not too absorbing, or of an unhealthy 
nature ; and he should (if the weather be suitable) take an ample amount 
of gentle out- door exercise. 

Good milk and eggs are probably especially valuable as articles of food 
for phthisical patients, but in their dietary frequent changes and consider- 
able latitude are often necessary ; and, further, alcoholic stimulants, 
though probably not essential, are often apparently very beneficial. For 
the purposes of bodily warmth flannel should be worn next the skin. 

The question of change of air is at this time one of the most moment- 
ous that can be raised. Shall the patient leave his home, and if so, 
whither shall he go, and when ? The great desideratum for phthisical 
patients appears to be a climate of moderate temperature, liable to slight 
variations only, and neither largely saturated with moisture nor of extreme 
dryness. It is exceedingly rare, however, for any climate to possess such 
uniformity of qualities during the whole year, and it is generally necessary 
therefore, in order to secure the full benefit of climate, to change the 
locality according to the season. And hence it will be understood that 
while most fairly healthy inland or seaside places in this country may suit 
phthisical patients reasonably well during the warmer months of the year, 
it will probably be necessary to select some sheltered spot upon the South 
Coast for winter residence ; that, while the bracing atmosphere of Scot- 
land or Sweden, or of the higher regions of Switzerland and Tyrol may 
be exceedingly suitable during the summer, the south of Europe, or the 
north of Africa, or the Azores or Canary Islands, may be especially bene- 



TUBERCLE. 401 

ficial during the winter. There is, however, large choice, and it may be 
added that a sea voyage is often of great service. But, notwithstanding 
the enormous benefits that not unfrequently accrue from judicious change 
of climate, or the permanent removal to a locality which experience may 
have shown to be specially suitable for the patient, it must not be forgotten 
that such changes often entirely fail to do good, and that they are alto- 
gether uncalled for and useless when the disease is acute in its progress, or 
far advanced. 

In addition to the above hygienic measures, and to the same end, it is 
generally advisable to have recourse to medicines. No drug with which 
we are acquainted has any specific influence over the tubercular process. 
But there are some drugs which, by improving the general health, tend 
indirectly to check its progress. Of these iron, quinine, and other vege- 
table bitters are amongst the most valuable. But there is one article — 
drug or food — namely cod-liver oil, which during the last thirty years has 
acquired a special reputation. There is little doubt on the part of prac- 
tical physicians, none on the part of the public, of the great value of this 
in the treatment of phthisical and scrofulous patients. It may be given 
in doses of from a drachm to an ounce three times a day. It is generally 
advisable, however, to begin with a small dose in order to avoid the. pro- 
duction of nausea, and prevent the patient from taking a dislike to it. It 
is now largely believed that the virtues of cod-liver oil depend simply 
upon the fatty matter of which it mainly consists ; and hence it has been 
assumed that other fats might prove equally beneficial. The use of cream, 
neat's-foot oil, olive oil, and other vegetable and animal fats, and of gly- 
cerine, has consequently been recommended. A great and sometimes 
insuperable bar to the administration of food, and to the use of the reme- 
dies which have been enumerated, is the irritability of stomach which is 
so often associated with phthisis. Hence, in a large number of phthisical 
cases, the condition of the stomach claims our first attention. It is impos- 
sible to lay down special rules for their treatment ; we must have recourse 
to some of the various measures which are serviceable in the more ordi- 
nary forms of dyspepsia, and above all, perhaps, we must adapt the tonic 
or combination of tonics we employ to the condition of the patient's 
stomach. 

A great part of the treatment of phthisis usually consists in treating 
symptoms as they arise. None of these symptoms probably is special to 
phthisis, and all may be treated in accordance with the rules which guide 
us under other circumstances. Local pains must be obviated by counter- 
irritation ; laryngeal affections by counter-irritation, by applications to the 
interior of the larynx, and by inhalation ; cough and expectoration, accord- 
ing to circumstances, by expectorants — ipecacuanha, and the like — astrin- 
gents, or sedatives ; diarrhoea by lead or tannic acid, or other of the 
numerous remedies which check intestinal secretion or assuage peristalsis. 
It must be added that, for the above and many other purposes, no one 
remedy is so generally useful as opium in its various preparations ; it relieves 
pain and discomfort, diminishes cough and expectoration, and restrains 
the action of the bowels. The nocturnal perspirations often defy treat- 
ment ; to check them it is desirable that the patient should not be heavily 
laden with bed-clothes, and that his room should be cool. The surface of 
the body too may be sponged before he goes to sleep. The mineral acids r 
oxide of zinc, and various other astringent remedies have been largely 
employed for the same purpose. Also food or wine given in the night 
26 



402 



DISEASES OF THE RESPIRATORY ORGANS. 



shortly before the hour at which perspiration usually occurs seems occa- 
sionally to prevent it. With the object of arresting haemoptysis, the use 
of ice and ice-cold drinks and foods, and the administration of astringent 
drugs, especially digitalis, lead, ergot, and gallic acid, are usually advo- 
cated. 

In conclusion, it may be pointed out that, while circumstances occa- 
sionally arise to render the local abstraction of blood or the use of emetics 
or purgatives necessary, all depressing treatment is, as a rule, to be 
eschewed ; that during the later period of the disease stimulants are often 
of extreme value ; and, further, that in cases of acute phthisis tonics, cod- 
liver oil, and change of air are usually equally valueless. 



VIII. SYPHILIS. 1 

Morbid anatomy 1. Larynx, trachea, and bronchial tubes. The 

mucous membrane of the larynx may become the seat of erythematous 
inflammation during that early period of syphilis in which the skin is 
similarly involved; and there may even be some excoriation of surface. 
At a later period, usually, mucous tubercles arise on the laryngeal surface, 
in common with that of the neighboring pharynx. These commence as 
small gland-like elevations, which gradually extend and coalesce. They 
may appear at any part — on the epiglottis and vocal cords, but especially 
(according to Dr. Mackenzie) on the inter-arytenoidean fold. They fur- 
nish a pretty abundant secretion, and tend to ulcerate — the ulceration 
extending both in surface and in depth, and leading, according to its situa- 
tion, to the more or less complete destruction of the epiglottis or vocal 
cords, and not unfrequently to caries or necrosis of the thyroid, cricoid, or 
arytenoid cartilages. During the so-called 'tertiary period' of syphilis 
gummata appear beneath the mucous membrane, involving not merely the 
connective tissue but the muscles and other parts. In this way tumors of 
considerable bulk may be developed. These, like other gummata, tend 
to undergo rapid degenerative changes, and to end in the formation of 
deep unhealthy-looking ulcers. All syphilitic ulcers when they extend 
deeply, are apt to involve the destruction of the cartilages, to lead to com- 
munication between the larynx and oesophagus, and to lay open arteries 
sufficiently large to allow of fatal hemorrhage ; and all, when they heal, 
leave dense reticulated cicatrices which not unfrequently produce serious 
contraction of the channel of the larynx. Syphilitic disease of the peri- 
chondrium may arise independently of ulceration or gummata, and lead to 
necrosis of the cartilages. 

Similar affections to those just described may involve not only the 
trachea, but probably also the bronchial tubes. There is reason to believe 
that a form of syphilitic erythema may attack the bronchia as well as the 
trachea ; and there is no doubt that syphilitic thickening of the mucous 
membrane and gummata of their deeper tissues are not altogether unfre- 
quent in both situations. These affections also in their further progress lead 
to ulceration, destruction of cartilages, and cicatrization with contraction. 

1 Syphilitic affections of the larynx and trachea have already been briefly con- 
sidered in connection with chronic laryngitis. 



SYPHILIS. 



403 



2. Lungs Syphilitic affections of the lungs are imperfectly understood. 

It is well known that syphilitic patients frequently become the victims of 
pulmonary phthisis, and the question has naturally presented itself whether 
the apparently tubercular formations in such cases may not be really 
syphilitic. The question is not altogether easy of solution ; for while, on 
the one hand, we have no reason to believe that the presence of syphilis 
excludes that of tuberculosis ; on the other, we know that there is a close 
anatomical resemblance between syphilitic gummata and tubercles. There 
is no reasonable doubt, however, that the lungs occasionally present specific 
syphilitic lesions ; and that these commence with proliferation of the con- 
nective tissue of the organ, therefore, beneath the pleura, around the 
bronchial tubes and vessels, and in the interlobular septa ; and terminate 
in the formation of ill-defined patches, in which the tissue is indurated, 
grayish, and contracted, and converted mainly into fibroid or cicatricial 
tissue, studded in some instances with caseous or calcareous nodules. The 
caseous nodules in the lung as elsewhere, though having a close resem- 
blance to tubercles, are usually much less friable than these latter are ; the 
fibroid growth differs little, if at all, from that observed in ordinary cases 
of chronic or fibroid pneumonia ; but Drs. Greenfield and Goodhart 1 point 
out that in its early stage it is characterized by great vascularity. It may 
be added, that the above growths are usually associated with syphilitic 
affection of the bronchial tubes, that they commonly abut on the surface 
of the lung, and that the pleura covering them is apt to be thickened, 
seamed, and puckered. Virchow and others have described a kind of 
ivhite hepatization of the lungs of stillborn syphilitic children, the origin 
of which they refer to the syphilitic poison. The lung, or lungs, or large 
portions of them, are dense, yellowish-white, opaque, tough, but retaining 
the impress of the finger. They have been observed in association with 
syphilitic pemphigus. 

Symptoms and progress The symptoms of syphilitic diseases of the 

larynx are essentially the same as those which have been ascribed to 
chronic laryngitis. The affection, however, especially if it be connected 
with the formation of mucous tubercles or of gummata, is extremely in- 
tractable, rarely terminating in complete restoration to health, and fre- 
quently leading to one or other of the graver lesions which have been 
enumerated. Syphilitic affections of the bronchial tubes equally simulate 
in their symptoms ordinary chronic bronchitis. 

With the few clinical facts which we possess in reference to the subject 
it would be a mere exercise of ingenuity to describe at length the symp- 
toms which may be produced by pulmonary syphilis. It will be sufficient 
to say that the diseases with which it is most likely to be confounded are 
chronic bronchitis, chronic phthisis, cirrhosis, and the consequences of 
these affections. Profuse haemoptysis would seem to be not uncommon. 
The presence of a history of syphilis, and of the superficial indications of 
syphilis, would, of course, furnish an important element of diagnosis. 

Treatment It need scarcely be said that, in treating syphilitic affec- 
tions of the larynx, trachea, bronchial tubes, and lungs, our main trust 
must be placed in ordinary anti-venereal remedies. 

1 'Transactions of the Pathological Society of London,' vol. xxviii. 



404 



DISEASES OP THE RESPIRATORY ORGANS. 



IX. TUMORS. 

A. Tumors of Larynx. 

Morbid anatomy — The larynx is a not unfrequent seat of adventitious 
growths. 1. Of non-malignant kinds the most common are fibromata. 
These may be simple tumors of a rounded or lobulated form, more or less 
distinctly pedunculated, and varying, it may be, from the size of a filbert 
downwards; or they may be similar bodies associated with more or less 
obvious overgrowth of the mucous glands and the formation of cysts; or 
they may have a papillomatous or warty character. The last are far more 
common than the others. They rarely exceed the size of a horse-bean, 
and are not generally larger than a split pea. They are, however, often 
multiple, and tend to spread over a considerable surface. Fibromata usu- 
ally originate on or near the vocal cords, but are not limited to these 
localities. They are not unfrequent in children, but may appear at any 
age. 2. Malignant tumors are mostly epitheliomatous, but are sometimes 
sarcomatous or cancerous. The first of these commences either in the 
pharynx, involving the laryngeal tissues secondarily, or at some part or 
other of the surface of the larynx. The others originate among the deeper 
textures. 

Symptoms and progress The symptoms to which simple polypi give 

rise creep on gradually, and probably consist at first in a little hoarseness 
or loss of voice, with a tendency to clear the throat or cough, and an occa- 
sional feeling as if there were some foreign body in the larynx. The phe- 
nomena, indeed, are undistinguishable at this time, except by means of 
the laryngoscope, from those of ordinary subacute laryngitis. At a later 
period their presence gives rise to more or less complete aphonia, to more 
or less serious impediment to respiration, and finally to death from asphyxia. 
If the laryngeal tumor be pedunculated, the symptoms are apt to vary with 
its change of position, and especially the patient is sometimes liable to 
sudden attacks of choking (which may at any time prove fatal), owing to 
the impaction of the tumor in the rima glottidis. If it be large as well as 
pedunculated, it may sometimes be seen at the back of the throat without 
instrumental aid. 

Malignant growths commence, like other growths, insidiously, making 
little show and producing few symptoms; and for awhile, indeed, there 
may be nothing to cause grave suspicion. Gradually, however, they en- 
large, form tumors which from their mere bulk interfere with respiration 
and other necessary acts, undergo destructive changes which give rise to 
copious discharges, involve the epiglottis, aryteno-epiglottidean folds, vocal 
cords, and other parts, and perhaps cause sinuses to form in the neck or 
openings between the larynx and oesophagus. Sometimes they lead to the 
erosion of arteries and sudden arterial hemorrhage. It must be added 
that carcinoma, commencing in the glandular or other tissues external to 
the larynx, occasionally involves that organ in the course of its extension, 
and sometimes, indeed, when the external tissues are largely infiltrated, 
the larynx gets imbedded in them and fixed. At first it is difficult, if not 
impossible, to recognize the presence of carcinoma, even on laryngoscopic 
examination. The rapidity of the growth of the tumor, however, the pro- 
gressive character and extent of the ulceration which attends it, the fetor 



TUMORS. 



405 



of its discharge, and the gradual involvement of the concatenate glands, 
all tend finally to render the diagnosis clear. 

Treatment. — Previous to the use of the laryngoscope, even simple tumors 
of the larynx were to a large extent fatal. They were then rarely recog- 
nized ; and being allowed to grow without let or hindrance, ended by 
asphyxiating the patient. With the laryngoscope, however, their recog- 
nition is, even if they be small, comparatively easy, and their cure for the 
most part a matter of little difficulty. If they be small or pedunculated, 
they may be removed by means of curved forceps of special construction — 
for those growing at the back or front forceps opening laterally ; for such 
as grow at the side forceps opening anteriorly and posteriorly. In some 
cases they may be removed by knife-edged forceps or scissors. It is in- 
expedient to employ much force, for the mere crushing which follows the 
attempt at removal (especially if it be repeated) often leads to atrophy of 
the growth. Occasionally, when the irritability of the larynx is extreme, 
or the patient is suffering from great dyspnoea, or under other special cir- 
cumstances, it becomes essential to perform tracheotomy previously to 
operating on the larynx itself. Astringent and other applications to the 
mucous membrane are of little or no use. The treatment of malignant 
affections of the larynx can never of course be curative; occasionally, 
however, some relief may be afforded by the various local measures which 
are serviceable in chronic laryngitis. In any case, tracheotomy is some- 
times necessary to prevent death from suffocation. 

B. Tumors of Lungs and Pleura. 

Morbid anatomy Non-malignant growths of the lungs and plurse are 

of little pathological and still less clinical interest ; malignant growths, on 
the other hand, are highly interesting and important. There is probably 
no form of malignant disease which has not been discovered at one time 
or other in these organs ; and probably each form has (apart from its 
microscopical characters) special peculiarities as to distribution, progress, 
and symptomatology. In the present state of our knowledge, however, it 
would be an excessive and needless refinement to discuss them separately. 

Malignant disease either originates within the lungs, or extends to them 
by continuity from the mediastinum or other adjoining parts, or is secondary 
to similar disease of some distant organ. In the first, case it usually con- 
stitutes a solitary mass ; in the second it often runs along the bronchial 
tubes ; in the third it is for the most part multiple. These several features 
are, however, by no means absolutely distinctive. The morbid process 
begins in the connective tissue, and therefore either in the walls of the air- 
cells, in the interlobular tissue, in the course of the bronchial tubes and 
their attendant vessels, or in the thickness of the pleural membrane and 
subpleural tissue. 

When the growth extends along the bronchial tubes the connective 
tissue which surrounds them becomes infiltrated and thickened, and the 
tubes and vessels set, as it were, in the solidified tissue. Moreover the 
walls of the bronchial tubes themselves ere long get involved ; in some 
instances those parts only which are external to the cartilages, in some 
those only which are internal to them, but for the most part their whole 
thickness. The affection of the mucous surface manifests itself by the 
appearance of small, disk-like elevations, which are at first scattered, but 
soon run together, forming a uniformly elevated slightly translucent tract, 



406 



DISEASES OF THE RESPIRATORY ORGANS. 



from which all the normal longitudinal and other markings are more or 
less completely effaced. Although the disease commences at the root of 
the lung, and is for the most part further advanced there than it is else- 
where, its distribution is not always continuous ; but tracts of healthy and 
diseased tissues and healthy and diseased tubes frequently alternate one 
w 7 ith another. 

Malignant disease, attacking the pleura and subpleural tissue, frequently 
appears in the form of small grayish lenticular thickenings, which have 
been likened to drops of tallow or wax. They are sometimes so little 
prominent and thin as to be scarcely visible ; sometimes they form very 
distinct papular or tubercular elevations. In its further progress, the 
former variety tends gradually to form tolerably uniform tracts of con- 
siderable extent; the latter variety tends to the production of pedunculated 
outgrowths, which may hang singly or in clusters into the pleural cavity, 
and may vary from the size (say) of a pin's head up to that of a bunch of 
currants, an orange, or a cocoanut. 

Whenever the morbid growth commences in the tissues which surround 
the bronchial tubes, or in the subserous tissue, there is a disposition for it 
to extend into the substance of the lung along the interlobular septa, and 
consequently for the affected lung to assume some of the characters which 
are so common in cirrhosis, and to some extent characteristic of it. 

In most cases malignant disease of the lungs shows itself in the form of 
one or more distinct tumors. These, while yet of moderate size, have a 
more or less rounded form, and if they abut on the surface often assume 
there the central depression and the tumid margin which are so common 
in hepatic cancer. When such tumors increase in size, as they usually 
do, with some rapidity, they become more or less irregular in form ; and, 
from the fact that they are then apt to get blended with the results of in- 
flammations and of pulmonary hemorrhage, their limits are often difficult 
to define. It must be added that in the progress of extension of malignant 
disease from the bronchial tubes or pleura, it is not uncommon for distinct 
tumors to form here and there in the lungs. Malignant growths of the 
lungs, like those of all other organs, tend rapidly to undergo degenerative 
changes, and hence soon break down and form vomicae. Not unfrequently 
sloughing takes place in them, and masses of the morbid tissue may become 
detached. 

Symptoms and progress The symptoms to which malignant growths 

of the intrathoracic respiratory organs give rise are, for many reasons, 
exceedingly variable. If the disease affect principally the serous mem- 
brane, the symptoms have a more or less close resemblance to those of 
ordinary pleurisy ; if the bronchial tubes be its main seat, the symptoms 
naturally approximate to those of bronchitis ; if tumors form, they may, if 
sufficiently large, afford the physical indications of consolidation ; and if 
they undergo softening, of the presence of vomicae, and may be attended 
with more or less abundant purulent or bloody, and probably fetid expec- 
toration. Still it must not be forgotten that malignant growths, in the 
early period of their formation, not unfrequently give no sign whatever of 
their presence, and that the patient may seem in fair, if not in his ordinary 
robust, health, up to the sudden supervention of some inflammatory com- 
plication or of haemoptysis. 

Malignant disease affecting the pleura generally ere long excites some 
inflammatory action, and the formation of false membrane, with temporary 
stitch and friction sound audible during respiration, and is probably always, 



TUMORS. 



407 



sooner or later, attended with effusion of fluid. This effusion usually gives 
rise to no symptoms beyond those due to the compression which it exerts. 
It tends so to accumulate as to distend the pleura, and is persistent, always 
returning and generally with rapidity after paracentesis. It is mostly 
mere ordinary dropsical serum. In some cases, however, it is distinctly 
inflammatory ; and it may be purulent. But it not unfrequently happens, 
especially if the adjoining lung-tissue be implicated, that it is mixed more 
or less copiously with blood, or that it is stained with altered blood-pig- 
ment, being green, yellow, or brown, or that it is glairy like the fluid from 
an ovarian cyst. 

When the bronchial tubes and the parts surrounding them are the chief 
seats of disease, the symptoms, as before indicated, are mainly bronchial. 
Assuming that the patient has never previously suffered from bronchitis, 
the symptoms would be characterized by their insidious approach ; but 
when so far developed as to be a source of distinct discomfort they would 
differ little if at all from those of progressive subacute or chronic bronchi- 
tis in some of its phases. There would probably at first be some difficulty 
of breathing, increased by exertion, with little or no distinct local evi- 
dence of lung-disease, or at most a little localized sibilant or sonorous 
rhonchus. With the advance, however, of the malady, secretion would 
take place from the affected tubes, and cough, with more or less abundant 
expectoration, would be added to the other phenomena. 

Small malignant growths within the lungs, even if numerous, yield no 
distinctive physical indications of their presence. They may, however, 
give rise to congestion, oedema, or inflammation in their vicinity, and may 
hence become revealed. Larger tumors are often solitary, and limited 
therefore to one locality ; but they may involve the whole of one lobe, or 
even more, of a lung. These, like smaller growths, are often associated 
with other local morbid conditions, which increase their apparent bulk and 
add to or aggravate the patient's symptoms. 

When malignant tumors are of sufficient size to be recognizable by 
physical signs, we find, in many cases, that there is dulness on percussion 
over the region which they occupy, and that there is also a total absence 
of healthy respiratory sound, of tubular breathing, of all forms of rhon- 
chus and crepitation, and of bronchophony, pectoriloquy, and vocal fre- 
mitus. The local indications, indeed, are rather those which we are accus- 
tomed to regard as characteristic of pleural effusion than those which we 
usually associate with consolidation. The explanation of this peculiarity 
lies in the fact that malignant growths usually form solid masses, the bron- 
chial tubes which permeate them being compressed or otherwise obliterated ; 
and that hence they are as distinct acoustically from the lung- tissue as is 
an accumulation within the pleura or the heart itself. There are many 
exceptions, however, to this rule — some due to the presence of surround- 
ing inflammatory changes, some to the continued patency of tubes and to 
the greater or less abundance of secretion in them, some to the formation 
of vomicae. The presence of malignant tumors in the lungs necessarily 
causes, sooner or later, more or less dyspnoea and cough, with expectora- 
tion which varies in its character — being sometimes at the beginning mere 
bronchial mucus, but later on becoming muco-purulent, and at length 
purulent, hemorrhagic, and fetid. Occasionally the sputa are glairy, and 
green, yellow, or brown — exactly like the fluid which is perhaps accumu- 
lating at the same time in the pleura. The general symptoms of malig- 
nant disease of the lungs are, for the most part, those of gradually increas- 



408 



DISEASES OF THE RESPIRATORY ORGANS. 



ing debility and emaciation, often associated with those of hectic fever, 
the patient at length dying exhausted, and sometimes before death passing 
into the typhoid state. Death may be due, however, less to the progress 
of the cancerous growths than to the secondary phenomena, such as pleural 
effusion and bronchitic obstruction, to which they give rise ; and hence it 
may occur at a comparatively early period of the disease, or, at all events, 
before the opportunity for accurate diagnosis has presented itself. 

It has been assumed, in the foregoing account, that the disease has 
primarily or mainly implicated the lungs or pleurae. It need scarcely be 
added that, when the thoracic affection is secondary to more advanced 
disease elsewhere, it very often fails to reveal itself by symptoms. Further, 
it will be readily gathered that the diagnosis of pulmonary or pleural malig- 
nant disease is often a matter of extreme difficulty — indeed, in most cases, 
it can only be arrived at by a very careful collation of all the facts of the 
case, and by close and continuous observation of the patient's progress. 
The presence of malignant growths elsewhere of course furnishes a most 
important clue. This clue is not likely to fail in cases in which the pul- 
monary affection is secondary and comparatively unimportant. It may be 
absent, however, from those cases in which its aid is most needed. Never- 
theless, careful examination should be made from day to day, for very 
often indeed in the progress of such cases enlargement of glands at the 
root of the neck, in the axilla or thoracic parietes, or development of 
growths in connection with the ribs or connective tissue of the thoracic 
walls becomes manifest, and throws a new and important light upon phe- 
nomena which were hitherto obscure. 

Treatment The treatment of malignant disease of the lungs and 

pleurae needs no special description. The treatment, already considered, 
of pleuritis, bronchitis, and pneumonia includes in some measure that of 
the several affections which have just been discussed — with the important 
reservation that all that can be done for malignant disease is palliative, 
and that therefore lines of treatment which may be pushed with advan- 
tage in the case of the inflammatory affections must be cautiously followed 
in respect of their malignant counterfeits. The relief of pain and dis- 
comfort, and the administration of nourishment, should be our chief aims. 



X. PARASITES. HYDATIDS. 1 

Morbid anatomy — The only parasitic disease of the lungs which has 
any practical interest is that due to hydatids, and this is of exceedingly 
rare occurrence in England. It appears to be common in Australia. 
There is usually only one tumor present, and this is said to be generally 
situated in the lower part of the right lung. The hydatid tumor may at- 
tain the size of a large cocoanut or exceed it ; may be situated (as it usually 
is) wholly within the substance of the lung ; or, originating beneath the 
visceral pleura, may form, as it were, an outgrowth from the lung into the 
pleural cavity. The walls of the cyst which contains the parasite vary in 

1 For fuller details in reference to the pathology, diagnosis, and treatment of 
hydatids we must refer the reader to the account of these parasites given further 
on amongst the diseases of the liver. 



PARASITES. HYDATIDS. 409 

thickness and density. The parasite is usually solitary, containing echi- 
nococci but not secondary cysts. Hydatids of the lungs, like hydatids 
elsewhere, are liable to cause serious consequences, either by the mere 
pressure which they exert, or by undergoing suppuration, or discharging 
their contents into the pleural cavity or bronchial tubes ; they are also 
liable to undergo degenerative changes with gradual contraction and cal- 
cification. 

Symptoms and progress Hydatid tumors of the lungs, when small, 

occasion little or no uneasiness, and necessarily therefore fail to be dis- 
covered. But as they enlarge they are after a while apt indirectly to 
cause bronchitic symptoms and occasional attacks of more or less profuse 
haemoptysis, and thus a series of symptoms which are exceedingly liable to 
be mistaken for those of phthisis. Their recognition may be rendered 
possible either by the special features of the tumors to which they give 
rise, or by the sudden expectoration of their contents. An hydatid cyst is 
always tense, and of a globular or ovoid form, and hence, when it attains 
any considerable size, tends, on the one hand, to cause a circumscribed 
bulging of the thoracic parietes with widening and more or less protrusion 
of the corresponding intercostal spaces, and, on the other hand, to displace 
the mediastinum and diaphragm. The localized bulging of the chest wall, 
with the possible detection of fluctuation and hydatid thrill, and the cir- 
cumscribed dulness on percussion which probably transgresses the median 
line of the thorax, without extending at the same time to its summit, are 
strongly indicative of the presence of a pulmonary hydatid, especially if 
these conditions have come on without febrile or acute symptoms and the 
general health of the patient has been, and remains good. There will 
also be over the area of dulness total absence of respiratory sound and 
vocal fremitus. It is stated that the voice sometimes presents at the mar- 
gins of the tumor an segophonic character. It need scarcely be insisted 
that the signs above enumerated are not absolutely pathognomonic of hy- 
datids ; they may be equally present (occasionally at least) in cases of 
circumscribed empyema or solid tumors. The rupture of an hydatid cyst 
and the escape of its contents into the bronchial tubes is attended with 
sudden suffocative cough and profuse expectoration, which may, according 
to circumstances, be limpid and watery, or purulent, and may contain 
echinococci, hydatids, or fragments of hydatid membrane. The detection 
of the parasites, either by the naked eye or by the microscope, necessarily 
removes all doubt as to the nature of the case. 

Hydatid tumors not unfrequently undergo cure — sometimes by sponta- 
neous retrogression, sometimes after the discharge of their contents by the 
bronchial tubes or some other route. On the other hand, the patient may 
die either suffocated by the sudden irruption into the air passages, or ex- 
hausted by long-continued suppuration, or from the rupture of the cyst 
into the cavity of the pleura and consequent empyema. 

It is in many cases impossible to distinguish accurately between hydatid 
tumors of the base of the right lung and those developed in the upper part 
of the right lobe of the liver. For the latter often protrude far into the 
chest, displacing the diaphragm and base of the lung upwards ; and cause 
marked bulging and dulness of the corresponding region of the thorax. 
Moreover they are very apt to perforate the diaphragm and to open either 
into the pleural cavity or into the lung itself, and in the latter case to dis- 
charge their contents by expectoration. When, however, hepatic hydatids 
are expectorated, biliary coloring matter is usually sooner or later mingled 



410 



DISEASES OF THE RESPIRATORY ORGANS. 



with them. On the other hand, hydatid abscesses of the base of the lung 
may perforate the diaphragm and so lead to the formation of abdominal 
abscesses. 

Treatment — There is little room for special treatment in the case of 
pulmonary hydatids. When, however, they are recognized as obvious 
tumors, they may be treated on the same principles as hydatids of the 
liver — a subject fully considered further on. 



XL BRONCHIECTASIS. (Dilatation of Bronchial Tubes.) 

Causation and morbid anatomy. — It is theoretically an easy matter, 
but practically very difficult, to draw the line between simple dilatation of 
bronchial tubes and vomicae which have become lined with a smooth mem- 
brane, and are in direct continuity with tubes. We make this distinction 
incidentally only, for our description of dilated tubes will embrace without 
distinction the several morbid conditions which are commonly confounded 
under the term. 

Dilated tubes then (using the term in its widest sense) may be arranged 
in three categories ; namely, 1st, that in which the dilatation involves the 
tubes in their whole length, and. is consequently cylindrical or monili- 
form ; 2d, that in which it affects only the terminal portions of the tubes, 
and assumes a globular form ; and 3d, that in which the expansions are 
large, more or less irregular in shape, and communicate with one or more 
bronchia. 

A. In the first of these varieties, the dilatation, which usually com- 
mences in tubes of the first or second order, is continued thence, with little 
or no interruption, through the succeeding tubes almost to their termina- 
tions in the air-cells. It is generally relatively greater in the smaller than 
the larger tubes ; the larger tubes indeed often being scarcely implicated, 
while the smaller measure from ^ to \ inch or more in diameter. Hence 
the affected canals form, in some cases, .a series of hollow cylinders of 
nearly uniform calibre ; in other cases a series of channels which actually 
increase in diameter towards their distal extremities, where probably they 
undergo in addition sudden and considerable enlargement. The dilatations 
are rarely, however, entirely uniform, but generally present a somewhat 
irregular or moniliform condition. The parietes of the dilated tubes vary 
in character ; sometimes they are generally thickened, sometimes exceed- 
ingly thin and delicate, sometimes the mucous membrane is fairly normal, 
sometimes thick, congested, and pulpy. In the larger tubes it often hap- 
pens that the fibrous and muscular bands stand out in strong relief, the 
interstices being correspondingly deep, and occasionally forming distinct 
pouches. This form of dilatation seldom involves both lungs at the same 
time, and still more seldom" the whole of one lung. It is most frequently 
met with in the lower and middle lobes, and even then is usually restricted 
to certain of their tubes only. The dilated tubes are in some cases sur- 
rounded by fairly healthy, in some by emphysematous, in some by collapsed, 
lung-tissue. Cylindrical dilatation of the bronchial tubes is probably al- 
ways secondary to chronic bronchitis, and more especially to capillary 
bronchitis with abundant accumulation of fluid ; and is due primarily to 



BRONCHIECTASIS. 



411 



the concurrence of inflammatory enfeeblement of the bronchial walls, and 
their distension by accumulated fluid contents. 

B. In the second variety, the expansion is limited almost exclusively 
to the terminal portions of the smallest bronchial tubes and bronchial pas- 
sages. The dilatations are globular or nearly so in form, and vary perhaps 
from the size of a small pea up to that of a filbert ; they present a smooth 
internal surface ; their parietes are comparatively thick, dense, and opaque ; 
and for the most part they communicate severally with a single bronchial 
tube, the orifice of communication with which is sometimes small and diffi- 
cult to find. In some cases such dilatations are scattered irregularly 
throughout emphysematous or otherwise diseased lung-tissue : in some 
cases they are grouped more or less thickly in some corner of a lung ; or 
they involve the whole of one lobe, or even of a lung. The lower lobe is 
most frequently affected. In the best-marked cases the whole of a lung 
or of its lower lobe is diminished in size, and riddled with globular cavities 
which are separated from one another by airless, collapsed, indurated lung- 
tissue. The history of these cases is usually very obscure ; but there is 
good reason to believe that they originate, not in ordinary chronic bron- 
chitis, but in either atelectasis, collapse, lobular pneumonia, or some other 
such condition. And it is probable that, in the first instance, the accu- 
mulation of muco-purulent fluid or of pus within the terminal bronchial tubes 
leads to the destructive ulceration of their walls and in a greater or less 
degree of the tissues which surround them ; that thus small cavities or 
vomicas, communicating with tubes, are formed within the solidified tracts 
of lung-substance ; and that finally each cavity attains a certain size, as- 
sumes a definite form, and becomes lined with a membrane continuous with 
that of the bronchial tubes. 

C. The third variety comprises those cases in which the lung contains 
one or more cavities, irregular in shape, and various but often considerable 
in size, each of which opens freely into one or two bronchial tubes. In 
some instances these cavities are solitary, situated in the apex, base, or 
elsewhere in the substance of the lung, and surrounded by or imbedded in 
dense fibrous or cicatricial tissue. In other instances the whole of one 
lobe, or the whole of a lung, contracted and cirrhosed, is studded with 
them. They are often lined with a perfectly smooth, polished membrane, 
continuous with that of the communicating bronchial tubes, but sometimes 
exhibit a more or less eroded or flocculent surface. In some cases they 
and the bronchial tubes connected with them present a thick, pulpy, deeply- 
congested lining, which may perhaps be undergoing excoriation. These 
cavities are not of course, strictly speaking, simple dilatations of tubes ; but 
obviously originate in vomicae — tubercular, pneumonic, gangrenous, or other. 
They are always surrounded with a greater or less abundance of indurated 
tissue, and in a considerable number of cases are associated with obvious 
or advanced cirrhosis. 

The determining cause of the several forms of bronchiectasis which have 
been considered is no doubt disease involving the bronchial tubes them- 
selves — disease attended with softening or destruction of their walls, and 
distension of their channels from undue accumulation of fluid within them. 
Yet it cannot be denied that other influences co-operate in some degree 
with these, the most efficacious of them being the constant tendency of a 
retracted side to recover its form, partly by its inherent elasticity, partly 
under the influence of the inspiratory efforts. It must be remarked, how- 
ever, that this latter influence can scarcely be operative unless the lung- 



412 



DISEASES OF THE RESPIRATORY ORGANS. 



tissue generally be indurated and reduced in bulk, and that in spite of it 
many vomicae contract, and some possibly cicatrize. 

Symptoms and progress — It will probably be gathered from the fore- 
going account of the morbid anatomy and causation of bronchiectasis that 
its special symptoms are in almost all cases necessarily mixed up with 
those of the maladies out of which it arises and with which it is associ- 
ated. Moreover, its own symptoms are not very characteristic. Those 
which may more especially be looked for are shortness of breath and 
cough, with abundant muco-purulent expectoration, not unfrequently 
mingled with blood, and occasionally fetid with a fetor which is little, if 
at all, distinguishable from that of gangrene. This is believed to be due 
to decomposition of the retained sputa. The physical signs which prob- 
ably present themselves are more or less retraction and immobility of one 
side or of a portion of one side of the chest, dulness on percussion, with 
large crepitation or gurgling, and other indications of the presence of 
vomicae. It must not be forgotten, however, that difficulty of breathing 
may be scarcely noticeable if one lung continue perfectly healthy, and 
that distinct indications of the presence of cavities are not likely to be 
observed if the cavities be small or deeply seated and surrounded with 
comparatively healthy tissue. Profuse and repeated attacks of haemop- 
tysis, due to intense inflammation and congestion of the lining membrane, 
or to its erosion, are not uncommon in the last of the three varieties of 
bronchiectasis, and occasionally cause death. The diagnosis of dilated 
tubes rests on a careful consideration of the history of the case, on the 
slow progress of the pulmonary lesion, or its limitation to one lung, and 
often to its lower half, and on the profuseness, long continuance, and often 
fetor of the expectoration. 

Treatment — No special treatment is required in bronchiectasis. For 
the most part, the rules which have been laid down for the treatment of 
chronic bronchitis are applicable here. 



XII. EMPHYSEMA. 

Causation and morbid anatomy — Emphysema is due to the dilatation 
and rupture of the air-cells of the lungs. Two forms of it have been 
described, namely, the interlobular and the vesicular : in the former of 
which air is extravasated into the interlobular spaces, whilst in the 
latter the dilated and ruptured vesicles communicate simply with one 
another. 

A. Interlobular emphysema, takes place only in those cases in which 
the pulmonary lobules are separated from one another by distinct intervals 
occupied by connective tissue. This anatomical peculiarity exists in the 
lungs of young children and of some of the lower animals, but is absent 
from the lungs of human adults. Interlobular emphysema is, therefore, a 
phenomenon of childhood only, and is occasionally observed, post mortem, 
in cases of hooping-cough, lobular pneumonia, and capillary bronchitis, 
especially where there have been repeated violent paroxysmal attacks of 
coughing. The escape of air into the mterlobular spaces is indicated 
anatomically by their marked dilatation and their occupation by what 
looks like strings of air-bubbles. The amount of emphysema present 



EMPHYSEMA. 



413 



varies greatly. In some cases, on section of the lung, merely a line or 
two of emphysematous tissue is observed. In other cases, the lobules are 
more or less extensively isolated from one another by a network of such 
tissue, and a similar mapping-out of them may be recognized on the sur- 
face of the lung. Occasionally it happens that the emphysematous condi- 
tion extends along the connective tissue which surrounds the bronchial 
tubes to the root of the lung, and thence diffuses itself into the mediastina, 
neck, face, trunk, and elsewhere. The latter phenomenon is more fre- 
quently the result of gross mechanical injury than of infantile pulmonary 
disorders ; and under such circumstances it is observed in adults as well as 
young children. 

B. Vesicular emphysema is a much more common and, on the whole, a 
much more serious affection than the last. It occurs, with certain differ- 
ences of character, under a variety of conditions. Thus, it is not unfre- 
quently met with in the lungs of persons dead of acute bronchitis ; it is an 
all but universal attendant on the chronic form of that disease ; it is one of 
the lesions which often accompany old age ; it is a frequent associated phe- 
nomenon of the degeneration of tubercular masses, or of the contraction, 
from whatever cause, of circumscribed bits of lung ; and it is also, as we 
believe, an occasional sequela of the obsolescence of scattered miliary tu- 
bercles. Under most of these conditions there has been persistent cough ; 
under several of them, enfeeblement of the walls of the air-vesicles or their 
involvement in destructive processes. 

1. The lungs of persons dead of acute bronchitis are often found much 
distended with air. They completely fill the portions of the thoracic 
cavity allotted to them, and do not collapse even after they are removed 
from the body. The air-vesicles are generally distended to the full, and 
the lung-tissue consequently is light, pale, and unusually spongy. This 
condition is always associated with obstruction of the bronchial tubes by 
secretion, and is primarily due to the comparative facility with which air 
is then drawn into the ultimate tissue of the lungs during inspiration, and 
the comparative difficulty with which it is then discharged during expira- 
tion. The appearance here referred to is very commonly regarded as an 
indication of emphysema. It is obvious, however, that there can be no 
disease of the air-cells, no vesicular emphysema, so long as the air-cells are 
simply distended and their walls remain sound. But when, as often 
happens at length, textural changes are superadded, when the walls of the 
air-cells become attenuated, bulging, perforated, and intercommunications 
between neighboring cells established, emphysema is really present. Never- 
theless, it is not always easy, either with the naked eye or with the micro- 
scope, to distinguish between mere over-distension of the air-cells and the 
beginnings of actual emphysema. 

2. The lungs of patients who have long suffered from chronic bronchitis 
are almost invariably emphysematous in a greater or less degree. When 
the emphysema is advanced and well-developed, the lung is usually of large 
size and exceedingly irregular in form — the increase of size and the irregu- 
larity being both due to the formation of clusters of emphysematous vesi- 
cles, which cause lobular, and in some cases pedunculated, protrusions 
from various parts of its surface. These are usually most abundant upon 
the anterior and outer surfaces of the lung, and especially upon its dia- 
phragmatic aspect. If the lung be full of air, the prominence of these 
clusters is unmistakable, and the relatively enormous size of their vesicles 
obvious on even casual inspection. On section, the emphysematous tissue 



414 



DISEASES OF THE RESPIRATORY ORGANS. 



collapses much more readily than the healthier tissue around. If the dis- 
tended lung be dried, before section, the distribution of the emphysema, 
not only at the surface but in the interior of the lung, may be easily recog- 
nized. The emphysema of chronic bronchitis has its origin, no doubt, in 
the emphysema of the acute disease, and comparatively slowly attains 
extreme development; and, like the last, it consists essentially in the atten- 
uation and perforation of the walls of the air-cells, the distension of the 
multilocular cavities thus produced, and the atrophy and disappearance, to 
a large extent, of the capillary networks of the affected regions. The 
emphysematous blebs may, roughly speaking, vary in size from that of a 
tare or pea up to that of a filbert or walnut. 

3. It is not uncommon to find a certain amount of emphysema in the 
lungs of old people who have never suffered materially from bronchitic 
symptoms. The emphysema here, however, is rarely extensive, and is 
often limited to the formation of fringes of emphysematous vesicles along 
the anterior and other short edges of the several lobes, and to the appear- 
ance of solitary vesicles scattered thinly over the general surface in con- 
nection with black pigmentary patches. When tubercular and other 
indurations and contractions take place in relation with any part of the 
pulmonary surface, so as to cause irregularity, puckering, and Assuring, 
well-marked emphysema (differing in no respect, except distribution, from 
that of chronic bronchitis) almost invariably manifests itself in the imme- 
diate vicinity. This variety of emphysema is most common at the apex. 
Again, emphysema arises in general but comparatively slight chronic dis- 
organization of the lung-tissue, general slight cirrhosis, or the obsolescence 
of widely distributed miliary tubercles. In these cases, as has been pre- 
viously pointed out, the lung-texture is coarse, permeated by a fine net- 
work of what looks like cicatricial tissue, in the meshes of which the 
dilated and ruptured air-cells are contained. 

The etiology of emphysema is a subject of much interest, and has largely 
occupied the attention of medical men. The theories which have been 
proposed in reference to it may be divided into three groups : the first of 
which attribute it to the dilating force exercised during the act of inspira- 
tion, the second to the pressure exerted during the act of expiration, the 
third to nutritive impairment of the walls of the air-vesicles. 

1 . When we consider that the healthy lung is accurately adapted to the 
cavity which contains it, and that no enlargement of the chest voluntarily 
effected can possibly dilate injuriously the healthy lung within it, it is im- 
possible to conceive that the emphysema of at least uncomplicated bron- 
chitis can be referred to the force with which the lungs are inflated. 
Matters, are, however, somewhat different when a lung, reduced in bulk 
by pleuritic adhesions or textural changes, is subjected to the rhythmical 
efforts of the corresponding thoracic wall to expand. It is conceivable 
then that while those parts of the lung, which are most firmly compressed 
or most dense from consolidation, would undergo little or no consequent 
change, those which are comparatively little compressed, or which are still 
fairly crepitant, might undergo disproportionate expansion, their air-cells 
might dilate, and their parietes become attenuated and finally ruptured. 
This indeed is the explanation commonly assigned to that form of emphy- 
sema which is developed in the vicinity of obsolescent tubercular masses 
and other patches of contracted indurated lung-tissue. It may be observed, 
however, on the other hand, that when, in lungs bound down and com- 
pressed by dense adhesions, portions of lung where the adhesions are thin- 



EMPHYSEMA. 



415 



nest expand and protrude beyond the general level, emphysema is certainly 
not commonly observed. 

2. During ordinary expiration, when the lung-texture retains its normal 
elasticity, and the bronchial and other passages are freely permeable, the 
air-cells are subjected to very little pressure. In all those acts, however, 
in which with closed glottis the expiratory muscles are called into vigor- 
ous action, the pressure on the surface of the air-cells and air-passages 
becomes augmented, and in some cases very greatly augmented. The acts 
to which we here refer are, in ascending order, speaking and shouting, the 
blowing of wind instruments, the expiratory shocks of coughing, and the 
straining efforts which attend defecation, parturition, and other forms of 
violent muscular exertion. But in these cases, again, if the passages are 
permeable the pressure is uniformly distributed, and injury to air-cells is 
little likely to result unless some of them have been previously impaired as 
to their power of resistance by morbid changes. The conditions, however, 
are altogether different when violent expiratory efforts are made, and made 
habitually, in the presence of obstructive disease of the bronchial tubes, 
whether the obstruction be due to accumulation of mucus or other matters 
within them, to thickening of their lining membrane, or to their compres- 
sion by morbid growths external to them. For it is easy to see that then 
while, during violent expiratory efforts, large portions of the lung whose 
tubes are little obstructed become comparatively empty, other portions 
(scattered probably among them) whose tubes are more completely ob- 
structed remain distended, and become in consequence unduly exposed to 
the compressing force exerted by the thoracic parietes. For equal extents 
of surface a globe holds more than any other solid figure; it is obvious, 
therefore, that if a full globe be compressed it must either yield or burst. 
The same remark applies to a distended air-cell or a group of distended 
air-cells ; and hence it is obvious that the effect of the expiratory com- 
pression of groups of full air-cells in connection with obstructed tubes 
must necessarily result in the expansion and attenuation of their walls, 
and sooner or later probably in their rupture. It is doubtless to this cause 
in large measure that the emphysema of bronchitis and the interlobular 
emphysema of childhood are due. 

3. Many years ago Mr. Rainey demonstrated the occurrence of fatty 
degeneration in the walls of the dilated air-cells in some cases of emphy- 
sema. We have already alluded to the occurrence of emphysema in con- 
nection with cirrhosis and obsolescent miliary tubercles. But indeed it 
will be admitted without further formal proof that the walls of air-cells are 
liable to get weakened, and to lose their ready distensibility, under these 
and many other conditions, such as old age, and various forms of inflam- 
matory and other processes. It is too obvious to need argument that en- 
feeblement of the walls of the air-cells must co-operate powerfully with the 
mechanical causes already discussed in the production of emphysema, and 
must, especially when of partial distribution, render even normal violence 
of expiration a source of danger. 

In concluding this brief discussion of the causes of emphysema it must 
be added that, although we have considered them separately, they probably 
always act more or less in concert. Thus, before the expiratory acts can 
cause compression and rupture of groups of air-cells, these must have been 
distended with air by more or less powerful efforts of inspiration ; and, 
even if the air-cells were previously healthy, their mechanical distension, 



416 



DISEASES OF THE RESPIRATORY ORGANS. 



attenuation, and laceration must result in more or less serious impairment 
of their powers of resistance for the future. 

Symptoms and progress — Emphysema in its slighter degrees is often 
present without causing distinct symptoms. Thus, in the limited emphy- 
sema which attends the obsolescence of tubercle, and in that which comes 
on in old age, there is often absolutely no sign to indicate its presence ; and, 
even in the emphysema of bronchitis, there are often at first, and even for 
a considerable time, no phenomena apart from those of persistent bron- 
chitis to justify its diagnosis. When, however, emphysema becomes con- 
siderable either in degree or in extent it can scarcely escape recognition, 
notwithstanding the fact that even then its symptoms are mainly those of 
bronchitis. 

The physical signs of advanced emphysema comprise alterations in the 
form and movements of the chest, together with percussive and ausculta- 
tory peculiarities. The chest tends to get dilated in all its dimensions, 
rounded from above downwards as well as horizontally, the ribs at the 
same time acquiring a less oblique direction than in health ; the form which 
it assumes is that to which the term ' barrel-shaped' has been applied. 
The shoulders become elevated, and the muscles of expiration (more par- 
ticularly those of the neck and shoulders) unduly prominent. At the same 
time the limits of the respiratory movements become narrowed, the chest 
during expiration retaining still the distended or barrel-like condition, and 
during inspiration undergoing little enlargement. On percussion there is 
usually increase of resonance over the chest, and more especially over those, 
portions of it which correspond to emphysematous areas ; and the precor- 
dial dulness is diminished in extent, or even abolished. The respiratory 
sounds are enfeebled. 

The symptoms referable to the lesion are shortness of breath, increased 
by exertion, and culminating at times in asthma-like attacks; duskiness 
and pallor of skin, and disposition on the slightest exposure to suffer from 
bronchitic attacks. Further, there is usually feebleness of pulse, and 
tendency to emaciation. The presence of any considerable amount of em- 
physema interferes seriously with the readiness of transmission of the blood 
through the lungs, and hence gradually the right side of the heart becomes 
hypertrophied and dilated, the cervical and other systemic veins get dis- 
tended with blood, the circulation is impeded in the capillary vessels of 
the extremities and internal organs, and general anasarca, congestion of 
liver with jaundice, and congestion of kidneys with albuminuria, super- 
vene. Indeed the consequences of emphysema are almost identical (ex- 
cluding congestion of the lungs) with those of mitral valve disease. 

Treatment — The treatment of emphysema must necessarily be indirect. 
We cannot, either by drugs or otherwise, restore the affected air-cells to 
their former condition. But what we can do, in many cases, is by suitable 
medicinal and hygienic treatment to cure or relieve the bronchitis which 
is so often associated with it, to prevent the recurrence of such attacks for 
the future, to relieve cough and dyspnoea, and to promote the general 
health. In addition, we may forbid all violent exercise and over-exertion. 
Easy circumstances, early hours, wholesome but not excessive diet, gentle 
exercise, warm clothing, a genial climate, together with the careful avoid- 
ance of everything calculated to give cold, constitute the main elements in 
the successful management of those who suffer from emphysema. For the 
treatment of its complications we must refer to what is said under their 
respective heads; and especially we must refer to the articles on bronchitis 
and asthma. 



CONGESTION. 



417 



XIII. CONGESTION. 

Causation and morbid anatomy. — Congestion always coexists with in- 
flammation. It frequently occurs, however, under other circumstances; 
and it is this variety that we propose now to consider. 

1. Congestion of the larynx, trachea, and bronchial tubes Simple 

hyperemia of these organs may result from obstructive disease of the 
right side of the heart or any other condition which causes accumulation 
of blood in the veins which lead from these parts, or it may be a sequela 
of repeated attacks of inflammation. 

2. Congestion of the lungs is an expression in constant use, but is pro- 
bably generally applied to cases of bronchial or pulmonary inflammation. 
Simple congestion, however, is of frequent occurrence, and is often a serious 
complication of other morbid conditions. It is an early and grave conse- 
quence of mitral valve disease, and other affections of the left side of the 
heart. It is a frequent complication of typhus and other infectious fevers, 
and even of the typhoid state. It doubtless also persists in some cases for 
a longer or shorter period as a sequela of inflammation. Congestion sec- 
ondary to heart disease is for the most part general, and is often followed 
by rupture of the small vessels of the lungs and extravasation of blood. It 
leads consequently to the condition known as pulmonary apoplexy and to 
haemoptysis. Further, it predisposes to pneumonia. The congestion which 
takes place in fevers is commonly termed ' hypostatci,' from the fact that 
it particularly affects the dependent, and generally therefore the posterior 
and lower, parts of the lungs. It is due, like the congestion which in the 
same affections occurs in other depending parts of the body, to feebleness 
of circulation and the disposition which the blood then has to yield to the 
influence of gravity. The affected portions of the lungs become dark, al- 
most black, with congestion, oedematous, more or less devoid -of air, heavy 
and lacerable : but they maintain their bulk, and generally crepitate in 
some degree. Not unfrequently this condition passes into pneumonia, and 
even gangrene. Congestion of the lungs, whether in connection with 
heart disease or febrile states, is always a matter of serious importance, 
partly because it indicates that there is something in the stage or nature 
of the malady which threatens danger, partly because it gives rise itself to 
serious symptoms, partly because it is apt to end, as the case may be, in 
pulmonary apoplexy, gangrene, or inflammatory consolidation. 

Symptoms — Of itself congestion of the air-passages is probably unim- 
portant, leading at most to some increased secretion from the mucous sur- 
face and its glandular follicles, and to habitual tendency to cough and 
hawk, especially on rising in the morning. It is chiefly serious because 
its presence greatly increases the liability to inflammation. The evidences 
of congestion of the lungs are mainly difficulty of breathing, with more or 
less lividity, and other asphyxial phenomena, cough with watery expecto- 
ration, and the presence of crepitating rales either generally distributed, 
or limited to or more pronounced in the lower and back parts of the lungs. 
The supervention of apoplexy, pneumonia, or gangrene, will be recognized 
by their special indications. 

Treatment — Very little can be done directly to relieve these mechanical 
congestions. It is sometimes, in cardiac cases, useful to remove blood by 
leeching, cupping, or venesection, or to act on the bowels or other emunc- 
27 



418 



DISEASES OF THE RESPIRATORY ORGANS. 



tories. But, for the most part, all we can do is to treat the heart affection 
on the principles elsewhere laid down, and the febrile disorder according 
to its general principles. 



XIV. DROPSY. HYDROTHORAX. 

Causation and morbid anatomy — GEdema constantly occurs as an inci- 
dent of the inflammatory process, tuberculosis, and the growth of malignant 
tumors. GEdema of the larynx, which is so often a cause of death, is al- 
most without exception the result of inflammation either of the larynx 
itself or of parts in its immediate neighborhood; pneumonic consolidation 
of the lung is usually attended with more or less oedema of the lung-tissue 
surrounding the consolidated district ; and pleurisy is rarely, if ever, unac- 
companied by serous effusion into the pleural cavity. Independently of 
inflammatory dropsy, however, which does not now concern us, there are 
other forms of dropsy, for the most part of mechanical origin, which are 
sufficiently important in their effects to call for a few remarks. Dropsy of 
the respiratory organs, like dropsy of other parts, may be due, equally with 
congestion, to certain forms of cardiac disease and other affections involv- 
ing obstruction of veins ; it may arise, also, in the course of renal disease ; 
and occasionally originates in mere anaemia. 

1. (Edema of the larynx may occur in the course of renal and heart dis- 
eases, and in those in which, from the presence of mediastinal tumors, the 
vena cava descendens, or the innominate veins are obstructed ; and pos- 
sibly may, even in its uncomplicated state, cause dangerous symptoms and 
death. Generally, however, when serious symptoms arise, inflammation 
has become superadded to the dropsy; and indeed the supervention of in- 
flammation doubtless constitutes the chief danger of this limited dropsy. 

2. (Edema of the lungs is a frequent accompaniment of general anasarca, 
from whatever cause : but is especially common in scarlatinal affection of 
the kidneys and other forms of Bright's disease ; and may occur in a high 
degree, even when there is little or no dropsy observable in other parts of 
the body. An oedematous lung is usually voluminous, heavy and pale, 
and on section large quantities of serous fluid mingled with air-bubbles 
drain away or may be squeezed out. It contains much less air proportion- 
ately to its bulk than natural, but is rarely quite devoid of air in any part. 
If the lung be at the same time congested, it combines the characters of 
congestion and oedema. In hypostatic congestion, which has been already 
described, there is usually such a combination. CEdema, like congestion, 
sometimes results in a form of pneumonic consolidation, and not unfre- 
quently in a condition of carnification or collapse. 

3. Pleural dropsy, or hydrothorax, occurs under the same circumstances 
as oedema of the lungs, and is very often associated with it in the sense of 
being complementary to it. That is to say, hydrothorax which is a serious 
and frequent item of general dropsy (whether cardiac, renal, or pulmo- 
nary), and tends for the most part to arise whenever oedema of the lungs 
tends to arise, serves nevertheless mechanically to exclude the latter con- 
dition, and conversely. Thus, if there be much pulmonary oedema there 
is probably little pleural effusion ; if much pleural effusion, little pulmo- 
nary oedema ; and if there be coincidence of pleural and pulmonary dropsy 



PULMONARY COLLAPSE. ATELECTASIS. 



419 



on the same side, the latter is limited to that portion of lung which lies 
above the level of the pleural exudation, the rest of the lung probably- 
being compressed, and void both of air and of excess of fluid. And further, 
it often happens that, if one lung be bound down by adhesions, the other 
being free, there is pleural dropsy exclusively upon the one side, pulmonary 
oedema exclusively upon the other. Occasionally hydrothorax becomes so 
considerable that it distends the pleural cavity and causes total collapse of 
the lung. 

Symptoms The symptoms of oedema of the larynx, so far as they are 

important, have already been fully considered. Those of oedema of the 
lungs are nearly identical with those of congestion of the same organs. 
There is gradually increasing difficulty of breathing with lividity of sur- 
face and other symptoms of defective aeration of the blood — symptoms 
which need not be rediscussed, but which, if not relieved, increase in 
severity until death takes place. There is usually also, sooner or later, 
more or less cough, with expectoration of thin serous fluid. The presence 
of oedema does not necessarily entail local indications ; the chest may be 
perfectly resonant, the breath sounds as nearly as possible healthy. Still, 
more or less crepitation may generally be recognized, especially behind 
and below ; and with the occurrence of consolidation the indications of 
that condition are necessarily developed. 

The general symptoms to which pleural dropsy gives rise are in the 
main those of pulmonary oedema. The local signs are those which have 
already been described as indicative of the presence of fluid in the pleural 
cavity (page 355). It may be observed that whenever difficulty of breath- 
ing and other signs of slowly developing asphyxia arise, in the course of 
renal or cardiac disease, or of suspected general tuberculosis, or malignant 
growths, it is important to examine the thorax carefully in reference to 
the probability of pleural dropsy being present. And further, in relation 
to this point it is worth while to remark that ithere is often much more 
fluid in a pleural cavity than might be suspected from casual examination. 
For in determining its presence and amount, the patient is usually made to 
sit up in bed and bend his trunk forwards — a position which necessarily 
throws the fluid forwards and reduces the height of the level of dulness 
behind in relation to the landmarks which usually guide us. 

Treatment — The treatment of dropsy of the larynx, lungs, and pleurae, 
resolves itself into that of the diseases which give rise to it. We must 
refer, therefore, to observations made elsewhere upon the treatment of in- 
flammations and tumors of these organs, and upon that of heart disease, 
bronchitis, and albuminuria. It may be pointed out, however, that when, 
even in advanced heart or kidney disease, or other affections, the patient 
with dropsical accumulation within the pleura is suffering much from 
dyspnoea, great (even though it be merely temporary) relief may often be 
given by the performance of paracentesis. The removal of even a few 
ounces of fluid by the aspirator may be sufficient for the purpose. 



XV. PULMONARY COLLAPSE. ATELECTASIS. 



Causation and morbid anatomy Under a considerable variety of cir- 
cumstances, more or less extensive portions of the lungs become void of 



420 



DISEASES OF THE RESPIRATORY ORGANS. 



air and shrink, assuming an appearance to which the term carnijication 
has been commonly applied. 

A. The simplest form of this condition is observed in a lung or part of 
a lung compressed by accumulation of fluid within the pleura. It is much 
reduced in bulk, wrinkled and livid on the surface, uniformly smooth, 
dark, and flesh-like on section (the bronchial tubes and larger vessels 
being compressed equally with the vesicular texture), tough but flabby in 
consistence, heavier than water, and capable of being reinflated through 
the bronchial tubes which lead to it. 

B. A second form is that which is frequently observed post mortem in 
the lungs of patients dead of bronchitis, fevers, or other affections in which, 
from debility or blocking up of some of the smaller bronchial tubes, respi- 
ration has been incompletely performed. Here the collapse does not as a 
rule involve any considerable continuous tract, but affects scattered groups 
of lobules, which are usually most abundant and largest in .the lower por- 
tions of the lungs. In such cases the lungs present considerable irregu- 
larity of surface — depressed livid-looking polygonal patches alternating 
with elevated tracts of comparatively pale and crepitant tissue. On sec- 
tion the depressed arese are found to correspond to dark-colored, airless, 
smooth, tough, carnified patches, which extend to various depths into the 
substance of the lung. In many cases a few such patches of collapse only 
are visible ; in others the collective bulk of collapsed lung-tissue is very 
considerable. 

Frequently, no doubt, the condition of the affected bits of lung here 
referred to is identical with that of lungs compressed by pleural effusion ; 
and in nearly all cases inflation may be readily performed. It must not 
be forgotten, however, that such collapse often takes place in lungs which 
are already congested or oedematous, when of course the shrinking is less 
pronounced, and the tissue is more juicy and lacerable than in simple col- 
lapse. Nor must it be forgotten that when the collapse is a complication 
of bronchitis, there is a tendency for it to pass into, or be associated with, 
lobular pneumonia ; and that then patches of apparently pure collapse are 
often associated with patches of distinct lobular pneumonia and other pre- 
senting gradations between these extremes. The main physical distinc- 
tions between lung-tissue consolidated from collapse and pneumonic lung 
are : the shrunken condition, the smooth, homogeneous, shiny, reddish- 
black sectional surface, and toughness of the former, the expanded, granular, 
lacerable, and, for the most part, pale reddish or grayish marbled aspect 
of the latter. 

The explanation of the production of the form of collapse now under 
consideration is not far to seek. Dr. Gairdner's theory is simple, and has 
found general acceptance. According to it, the smaller tubes get more or 
less completely filled with mucus, which acts in each case as a valvular 
plug, preventing the passage of air beyond it, during inspiration, by be- 
coming then more tightly wedged in the narrowing tube, but allowing the 
escape of air from the implicated air-cells during expiration by being then 
driven into the wider portion of tube above. It is not quite clear, how- 
ever, that mucus is generally capable of performing this twofold action ; 
nor is it essential that it should so act in order that collapse shall be pro- 
duced. The simple but complete and prolonged obstruction of a small 
tube is amply sufficient to cause collapse of the portion of lung to which it 
leads — the obstruction preventing both ingress and egress of atmospheric 



HEMORRHAGE. 



421 



air, and the tissues beyond gradually absorbing that which is imprisoned 
within them. 

C. A third form of what may also be conveniently termed collapse is 
known by the name of ' atelectasis. ,' This is really the persistence of the 
foetal state of lung, in which the condition of things is little, if at all, dis- 
tinguishable from what obtains in simple collapse. 

Symptoms and progress — In discussing the morbid anatomy and symp- 
toms of collapse, it is so usual to confound it with lobular pneumonia (with 
which it is frequently associated), that the result is less an account of col- 
lapse than of inflammation. Collapse is, for the most part, a mere conse- 
quence of other lesions, and gives rise to but few distinctive symptoms. 
Nevertheless, there are some cases in which, doubtless, its occurrence 
aggravates the patient's symptoms and diminishes the chances of his 
recovery. This is more especially the case in bronchial affections, hoop- 
ing-cough, measles, and the like, occurring in young children. For in 
them, owing to the yieldingness of the thoracic walls, perfect inflation of 
the lungs under difficulties is often impossible, the flexible framework of 
the chest failing to respond to the efforts of the inspiratory muscles. The 
symptoms to which extensive collapse may be expected to give rise are in 
the main those which attend congestion and oedema, namely, gradually 
increasing dyspnoea, with the other consequences of defective aeration of 
the blood. We have already, in discussing the subject of bronchiectasis, 
adverted to the fact that collapsed lung-tissue, whether the collapse be of 
the nature of atelectasis, or due to pressure, or bronchial affection, may 
remain permanently solid, and pointed out that there is good reason to 
believe that it is in such conditions that bronchiectasis with globular dila- 
tations not unfrequently takes its origin. It may be added that extensive 
collapse of lung-tissue is necessarily associated with depression and com- 
parative immobility of the thoracic parietes in relation with the affected 
tracts ; and that hence in young children there not unfrequently results 
permanent impairment of the form of the chest, the lower half usually be- 
coming contracted in the horizontal plane, while the upper remains nor- 
mally, or even becomes abnormally expanded. 

Treatment Pulmonary collapse, apart from the bronchial and other 

affections which attend it, and the permanent consequences which it some- 
times entails, scarcely calls for special treatment. 



XVI. HEMORRHAGE. PULMONARY APOPLEXY. 
HiEMOPTYSIS. 

Causation and morbid anatomy Hemorrhage from the respiratory 

organs may be of two kinds : — first, that in which the blood is yielded by 
some part of the air-passages or cavities in direct continuity with them ; 
and, second, that in which it takes place primarily into the substance of 
the lungs. 

1. The former kind is due to either congestion, inflammation, ulceration, 
or injury; and may occur in the course of simple or ulcerative inflamma- 
tion of the larynx, trachea, or bronchial tubes ; or attend syphilitic, car- 
cinomatous, or tubercular affections of the same parts ; or take place during 
the process of detachment of the membranes of diphtheria or plastic bron- 



422 



DISEASES OP THE RESPIRATORY ORGANS. 



chitis, of the discharge of hydatids or of the opening of abscesses. It 
may be due also to the rupture of an aneurism into the trachea, bronchial 
tubes, or pulmonary vesicles. In these cases the hemorrhage takes place, 
either from numbers of minute vessels, or from one vessel of compara- 
tively large size which has undergone ulceration or rupture. 

If the blood thus effused be small in quantity, it is usually mingled with 
the sputa in the form of spots or streaks. If it be more abundant, it be- 
comes more generally diffused throughout their mass. When profuse it 
not unfrequently accumulates in the cavities or tubes which yield it, or 
finds its way by the effects of gravity or of inspiration into healthy tubes, 
and even into those of both lungs. Under the latter circumstances it is 
apt to coagulate and form solid casts of the channels in which it lies. It 
is said that blood yielded by the bronchial or other passages may be sucked 
into the air-cells, and thus cause pulmonary apoplexy. This we are not 
disposed to admit. 

2. The second variety of hemorrhage takes place into the interalveolar 
texture of the lungs and air-cells ; and the extravasated blood tends partly 
to be expectorated, partly to accumulate in the tissues, producing the con- 
dition termed 'pulmonary apoplexy. ' This form of hemorrhage attends 
pneumonia, but is rarely excessive in that disease, or productive of apo- 
plexy. Pulmonary apoplexy is much more common in lobular pneumonia 
and pyaemia. Its most frequent cause, however, is heart disease, attended 
with impediment to the passage of blood through the left cavities, or with 
extreme feebleness of circulation. Further, pulmonary apoplexy not un- 
frequently complicates Bright's disease in its advanced stages, embolism of 
the pulmonary artery, and those cases in which, whether from debility or 
other causes, there is a disposition to the formation of coagula in the vessels 
generally. 

Pulmonary apoplexy is indicated post-mortem by the presence of patches 
of lung tissue of various sizes, from that of a pulmonary lobule up to that 
of a hen's egg, or larger, which are for the most part distinctly limited by 
the margins of the outermost of the affected lobules, are distended like 
pneumonic tissue, are of a dark, reddish-black color like colored clots un- 
exposed to the atmosphere, contain little or no air, yield a small quantity 
of sanious perhaps frothy serum on pressure, and are heavy, and more or 
less brittle or lacerable. The patches which may be present display great 
variety, both in number and in size ; and they may occur in any region of 
either lung; but are more common below than above. The presence of 
pulmonary apoplectic effusions is usually associated with that of moulded 
adherent clots in the arterial branches leading to them, to the formation of 
which thrombi, indeed, there is reason to believe that they are often, if not 
always due. Apoplectic clots undergo decolorization, as does blood effused 
into the subcutaneous tissues ; and if small may disappear, leaving behind 
them some brownish granular pigment only. Sometimes they soften and 
break down ; and generally they induce inflammatory mischief in the lung- 
tissue around them and the pleural surface upon which they abut. The 
surrounding inflammation is sometimes pretty extensive, and the blending 
of the two morbid conditions may make it difficult or impossible to deter- 
mine the relation between them, or to define their respective limits. 

3. Besides the above varieties of hemorrhage there are others dependent 
on constitutional disorders which may affect indifferently the parenchyma 
of the lungs, and the mucous membrane of the air-passages, or are of 
uncertain origin. Such are the hemorrhages, which attend purpura, 



HEMORRHAGE. 



423 



typhus, smallpox, diphtheria and similar diseases, that which is said to 
occur vicariously of menstruation, and that due to diminished atmospheric 
pressure. 

Symptoms and progress. — It is not usually a difficult matter to deter- 
mine whether blood voided by the mouth is derived from the respiratory 
organs or not. The fact that it is expelled by coughing, and has a florid 
frothy character ; the detection by auscultation of crepitation in one lung, 
or part of a lung ; and (if its source be apoplectic) the recognition of dull- 
ness and of the other local indications of pulmonary consolidation, will of 
course be important aids to diagnosis. Further, careful inquiry into the 
history of the patient, and examination of his thoracic organs will, in a 
large proportion of cases of haemoptysis, reveal the presence of organic 
pulmonary, cardiac, or arterial disease. At the same time we must not 
forget to look to the nose and fauces, in order to be sure that the blood is 
not yielded by these parts, and especially to determine, so far as may be, 
the condition of the oesophagus and stomach. Still it is quite possible to 
make mistakes in spite of the most anxious care ; and it is important, 
therefore, to bear in mind the following considerations : first, hemorrhage 
may take place from the lungs, and yet no other evidence of thoracic dis- 
ease be present; second, it may, especially if it be from the larger air- 
passages, be so sudden and profuse that the blood pours from the mouth 
without any effort at coughing, and even with more or less of the sensa- 
tion and appearance of sickness ; third, although the blood of haemoptysis 
is usually described as frothy and scarlet, when it escapes in large quanti- 
ties its color may be that of blood in any other form of hemorrhage, and 
devoid of marked frothiness ; and when it has lain in bronchial tubes or 
cavities, or has been derived from apoplectic effusions, it not unfrequently 
is dark-colored or almost black, or of a more or less dull chocolate or 
coffee-ground hue ; fourth, in profuse pulmonary hemorrhage blood may 
be swallowed in considerable quantity and subsequently vomited or passed 
by stool, while, on the other hand, in haematemesis or epistaxis, blood 
sometimes finds its way into the air-tubes, and is discharged thence by 
coughing. When pulmonary hemorrhage is slight, as it generally is in 
bronchitis, pneumonia, and pulmonary apoplexy, the symptoms to which 
it gives rise are unimportant ; when, however, it is profuse, as it often 
proves in phthisis or carcinoma, or when an artery or vein is perforated or 
an aneurism ruptured, the symptoms and prospects are in the highest 
degree grave. The patient frequently dies suddenly, either choked by the 
violent outburst, or rendered syncopic from the loss of blood ; or sinks at 
an early period from the effects of repeated hemorrhagic .attacks. 

Treatment Many of the varieties of pulmonary hemorrhage do not call 

for special treatment, and indeed, in the great majority of cases, the hemor- 
rhage must be attacked through the disease to which it is due. This rule 
applies in great measure even to cardiac and phthisical haemoptysis. When, 
however, the discharge is profuse, or threatens to become profuse, or in 
any way specially dangerous, it calls for prompt treatment. The patient 
should be kept perfectly still, in the recumbent posture, and every means 
of quieting the circulation should be adopted ; no exertion, not even that 
of speaking, should be permitted ; he should be placed in a cool room, and 
be but little oppressed with bed-clothes ; ice-bags may be applied to his 
chest ; his food should be unstimulating, and but small in quantity ; he 
should have cold drinks or ice to suck, and for medicinal remedies such as 
quiet the circulation or contract the smaller arteries, among which may 



424 



DISEASES OF THE RESPIRATORY ORGANS. 



especially be named lead, gallic acid, digitalis, ergot, and turpentine. Local 
or general bleeding may, in some cases, be justifiable. The treatment of 
internal hemorrhage is, however, always eminently unsatisfactory. 




XVII. PNEUMOTHORAX. 

Causation and morbid anatomy The presence of air in the cavity of 

the pleura is probably always referable to the existence of some communi- 
cation between that cavity and the external atmosphere. Thus, it may be 
due to a wound, such as is made in paracentesis or Avhen the pleura is 
punctured in the carelessly performed operation of tracheotomy ; or to the 
opening into the pleura of an abscess already communicating with the 
exterior, such as one in the parietes of the chest, or an hydatid or other 
abscess of the liver. Its most frequent causes, however, are the discharge 
of an empyema through the lungs or thoracic parietes, and the opening of 
a tubercular or other pulmonary abscess into the pleural cavity. It is said 
to be caused sometimes by the rupture of emphysematous vesicles, some- 
times by the decomposition of fluid and solid matters occupying the pleural 
cavity. 

Pneumothorax, even if it do not commence from empyema, is probably 
always followed sooner or later by inflammatory effusion into the pleural 
cavity, and by the formation of pus. If it affect a circumscribed portion 
only of the pleura there is little or nothing by which it can be distinguished 
practically or clinically from a pulmonary vomica. The most striking 
cases are those in which a sudden and free communication takes place 
between the lung and a pleural cavity which had previously been healthy. 
Then air is admitted into the cavity with each inspiratory act, and, not 
being again expelled, accumulates at the expense of the lung, which under- 
goes gradual compression, of the mediastinum which becomes displaced to 
the opposite side, of the diaphragm which is pushed downwards, and of the 
outer thoracic parietes, which become distended and immovable. The 
accumulation of air acts, indeed, mechanically in precisely the same way 
as the accumulation of fluid. 

Symptoms and progress The symptoms which mark the occurrence 

of pneumothorax are, for the most part, more or less sudden pain or un- 
easiness in the affected side, but especially the sudden supervention of 
severe and increasing dyspnoea. They are identical, as nearly as may be, 
with those of dropsical accumulation, but are much more rapid in their 
development. It need scarcely be added, however, that when the pneu- 
mothorax supervenes on empyema, or occurs within a limited space, no 
special symptoms may be developed. The physical signs have been already 
considered. They are mainly, in addition to distension and immobility of 
the affected side, hyper-resonance on percussion, absence of respiratory, 
murmur, with cavernous and metallic sounds, and diminution of vocal 
fremitus. The supervention of empyema, and the accumulation of fluid in 
the pleural cavity, lead to the production of additional physical phenomena 
t which have already been sufficiently described. 

Treatment. — The treatment of pneumothorax is in the main that of 
empyema. It may, however, be pointed out that, when intense dyspnoea 
comes on rapidly, it may be necessary' to remove the accumulated air by 
paracentesis. 



PARALYTIC AFFECTIONS OF THE LARYNX. 



425 



XVIII. PARALYTIC AFFECTIONS OF THE LARYNX. 

These affections are very various in their origin. They may be due to 
mere functional disturbance, as in hysteria and loss of power of phonation 
from sudden fright or other mental disturbance; to diphtheria; to cerebral 
disease; to lesions of the pneumogastric trunk, or of the superior or recur- 
rent laryngeal nerves. Further, from various causes, atrophy of one or 
more of the laryngeal muscles may take place. 

1. a. Bilateral paralysis of the superior laryngeals is a rare affection, 
and usually due to either hysteria, bulbar paralysis or diphtheria. The 
superior laryngeals are the sensory nerves of the larynx, but supply motor 
branches to the crico-thyroid muscles exclusively, and, in conjunction with 
the recurrents, to the arytenoidei. They are also, according to Von 
Ziemssen, the motor nerves of the depressors of the epiglottis. The con- 
sequences of their paralysis would therefore be, anaesthesia of the larynx, 
inability to depress the epiglottis, and inability also to make the vocal 
cords tense. The symptoms would be some degree of hoarseness of voice 
with incapability of uttering high notes ; and, in consequence of the asso- 
ciation of loss of sensation with failure of the epiglottis to descend, tendency 
for the food to enter the rima glottidis, but without the immediate spas- 
modic choking which naturally attends that accident. Under laryngoscopic 
examination, we should expect to see perfect execution of the movements 
of adduction and abduction. 

b. Unilateral paralysis of the superior laryngeals may result from the 
implication of the nerve in various morbid processes. The symptoms 
would be of the same nature as those observed in the double affection, but 
less pronounced, and of course the anaesthesia would be limited to one side. 

2. a. Bilateral paralysis of the recurrent laryngeals arises from the 
same causes as induce paralysis of both superior laryngeals. The recurrent 
nerves supply all the intrinsic muscles of the larynx, with the exceptions 
above specified. There is therefore in this affection loss of power mainly 
in the muscles which open and close the glottis. Under the laryngoscope 
therefore the cords will be found to lie nearly motionless, midway between 
their position in complete closure of the glottis and that which they occupy 
when the glottis is widely opened. They do not approximate in phonation, 
but they tend mechanically to fall together during deep inspiration. The 
symptoms of the disease are: complete aphonia, with undue expenditure of 
breath during forcible expiration, as when the patient attempts to phonate 
or coughs; and inability to cough or expectorate with vigor. There is ab- 
sence of dyspnoea, at any rate during quiet breathing. 

b. Unilateral paralysis of the recurrent laryngeals is usually referable 
to intra-thoracic disease or tumors occupying the lower part of the neck, 
especially to aneurism and carcinoma; occasionally also to enlargement of 
the thyroid body. It is an affection of tolerable frequency, and of great 
significance. When it is present the affected vocal cord remains motionless 
midway between the position of closure and that of complete patency, while 
the opposite healthy cord tends during phonation to pass beyond the median 
line, and thus to render the rima glottidis oblique. The voice loses its 
clearness and purity, and tends to break into a falsetto when the patient 
tries to speak loud. He is doubtless also liable to some degree of occa- 
sional dyspnoea. Indeed, it is generally held that one of the consequences 
of this form of paralysis is the occurrence from time to time of spasmodic 



426 



DISEASES OF THE RESPIRATORY ORGANS. 



attacks of intense difficulty of breathing and cough, which are apt to prove 
fatal. This, however, we believe to be an error, and are ourselves disposed 
to refer the dyspnoeal attacks which are so common in these cases to con- 
current compression of the trachea, which is often induced by the same 
affection as induces the paralysis. 

3. a. Bilateral paralysis of the pneumo gastric nerves is most frequently 
observed in hysterical patients, and may be induced in them by the occur- 
rence of slight laryngeal inflammation, or under the influence of emotion. 
It may also be a sequela of acute laryngitis or diphtheria, and of sudden 
fright, horror, or grief. It is probably never complete, and rather reveals 
itself by imperfect action of the muscles than by their entire immobility. 
The symptoms, which include aphonia and more or less breathlessness, need 
no detailed description. Its duration, curability, and liability to recur 
depend in great measure on its cause. As, however, it is almost invariably 
functional, a complete cure may generally be anticipated. 

b. Unilateral paralysis of the pneumoyastric nerves, that is, palsy in- 
volving loss of sensation as well as loss of motion on the affected side, is 
rarely if ever met with as an element of ordinary hemiplegia. It has been 
observed, however, in the case of tumors involving the nucleus of origin 
of the nerve in the medulla oblongata, and may be induced by the acci- 
dental division of its trunk in the neck, or its implication in the progress 
of morbid growths, above the giving off of the laryngeal branches. When 
the disease is in the medulla oblongata there must almost necessarily be 
involvement either of the hypoglossal or of some neighboring nerve, or 
other paralytic phenomena — a combination which would probably render 
the diagnosis comparatively easy. In other cases, the existence of some 
lesion on the corresponding side of the neck would probably explain the 
nature of the laryngeal affection. The symptoms would be almost identical 
with those of paralysis of the recurrent laryngeal. Anaesthesia would pro- 
bably be overlooked, unless attention were specially directed to the possi- 
bility of its presence. 

4. a. Bilateral paralysis of the posterior crico-arytenoidei is of very 
rare occurrence, and its causes are very obscure. It may come on at any 
age. These muscles open the glottis ; and the consequence of their paral- 
ysis is tltat the adductor muscles being unopposed tend to transform the 
glottis into a narrow chink, which narrows itself still further during inspi- 
ration. The essential symptoms of the affection are the gradual develop- 
ment of a purely inspiratory dyspnoea, generally without catarrh or disturb- 
ance of voice. At first the inspiratory stridor comes on only when some 
unusual bodily exertion is being made ; but it gradually becomes permanent, 
even when the patient is at complete rest. It is especially obvious when 
he is asleep. At the same time expiration is performed without difficulty, 
and the voice remains clear. The disease is always chronic, and rarely 
if ever curable. Tracheotomy is almost always needed ultimately. 

b. Unilateral paralysis of the crico-arytenoidei In this case the inner 

border of the affected vocal cord stands in the median line. The voice is 
somewhat impure ; but it is only during forced inspiration that coarse loud- 
sounding vibrations are produced. 

5. Paralysis of the lateral crico-arytenoidei (adductors) causes much 
the same symptoms as paralysis of the recurrent laryngeals. The vocal 
cords (one or both) remain wide open ; there is absolute aphonia and 
undue expenditure of air in speaking and coughing. 

6. Paralysis of the arytenoideus. — This muscle draws the arytenoid 



SPASM OF THE LARYNX AND TRACHEA. 



427 



cartilages together. When, therefore, it is paralyzed, the part of the rima 
glottidis bounded by the arytenoid cartilages remains open during phona- 
tion, forming a triangular chink; while the vocal cords in the anterior 
two-thirds come into absolute contact. The result is that unvocalized air 
escapes through the chink when the patient speaks loud, and the quality of 
the voice becomes impaired or hoarse. This affection is usually the con- 
sequence of acute catarrh, but is rare. 

7. Paralysis of the thyro-arytenoidei These are more commonly 

affected than any of the other muscles of the larynx, in catarrh, over-exer- 
tion in speaking or singing, and hysteria. Their paralysis is indicated by 
loss of tension in the vocal cords, so that when they are brought into appo- 
sition an oval slit is still left between them. The symptoms are hoarseness 
and impurity of voice. 

Treatment In the treatment of functional paralysis, the general health 

of the patient must be carefully considered, and as far as possible improved. 
But local treatment is especially important. For this purpose counter- 
irritation externally, and stimulating applications to the mucous membrane, 
are often useful. No local measures are so generally efficacious as the ap- 
plication of galvanism. This may be effected by placing the electrodes on 
either side of the exterior of the larynx, or (with the aid of Dr. Macken- 
zie's or some other suitable apparatus) one within and one in contact with 
the skin over the situation of the thyroid cartilage. The treatment of 
other forms of paralysis is involved in that of the conditions which give 
rise to them. They are often incurable. 



XIX. SPASM OF THE LARYNX AND TRACHEA. 

1. Larynx Spasm is chiefly known as causing contraction of the rima 

glottidis. It is rarely an independent affection, but is of common occur- 
rence as a complication of other disorders. It is an essential element in 
hooping-cough, spasmodic croup, and the true epileptic seizure ; it is readily 
induced by the inhalation of irritating vapors, or the entrance of solid or 
fluid matters into the larynx; and it is frequently associated in a greater 
or less degree with inflammatory affections of the larynx. It may also be 
a phase of hysteria. Prolonged spasmodic closure of the glottis, or laryn- 
gismus stridulus — a kind of epileptic convulsion — is occasionally fatal in 
young children. 

2. Trachea. — That spasmodic contraction of the trachea may take place 
is a physiological fact. How far it is a matter of any importance is another 
question. We allude to it here, however, because we believe that when 
aneurismal or other tumors are compressing the trachea and inducing from 
time to time spasmodic attacks of dyspnoea, the immediate cause of diffi- 
culty of breathing is not unfrequently spasmodic contraction of the mus- 
cular tissue of the compressed portion of the trachea, associated, it may 
be, with more or less hyperemia and accumulation of mucus. 

Treatment — For the relief of laryngeal spasm the following measures 
may be serviceable : namely, the application of leeches, counter-irritants, 
or hot fomentations to the upper part of the chest in front, or to the neck ; 
or the employment of hot baths, while cold water is dashed into the face ; 
and, for internal use, emetics, sedatives, and the inhalation of chloroform. 
Tracheotomy may be necessary. 



428 



DISEASES OF THE RESPIRATORY ORGANS. 



XX. ASTHMA. (Spasm of the Bronchial Tubes.) 

Definition The term asthma is often applied loosely to various forms 

of difficulty of breathing, and indeed, is very commonly employed to de- 
signate the dyspnoea which attends ordinary chronic bronchitis and em- 
physema, or cardiac disease, or that which is due to the pressure of tumors 
upon the trachea. We use the term here in its more correct and restricted 
sense to indicate a specific affection, characterized by the periodic recur- 
rence of general contraction of the bronchial tubes and consequent dyspnoea, 

Catisa.tion — Asthma is not unfrequently inherited — asthmatic parents 
begetting asthmatic children. It has also been observed occasionally to 
have a similar relation with epilepsy and other spasmodic nervous disor- 
ders. It affects males about twice as frequently as females. It may make 
its first appearance at any period from birth up to extreme old age ; but 
most commonly commences during the first ten years of life. The first 
outbreak is often traceable to an attack of hooping-cough, measles, or bron- 
chitis ; but in a large proportion of cases, no such explanation of its origin 
can be discovered. When, however, patients have become asthmatic, 
paroxysms of dyspnoea may be excited by a wide range of conditions, which 
are unequally operative in different cases, and some of which are not im- 
probably capable of originating the disease. Of these some appear to act 
directly, others indirectly, upon the bronchial tubes. Of the former, Dr. 
Hyde Salter gives a long and interesting list, which includes : the inhala- 
tion of smoke, dust, or pungent vapors; the smell of cats, dogs, horses, 
rabbits, or other animals ; the scent of the rose, privet, or other flowers ; 
the emanations from new-mown hay and powdered ipecacuanha ; change 
of weather, the prevalence of particular winds, and the presence of fog. 
But the most curious and mysterious of such causes is simple change of 
locality. Thus, some asthmatics suffer most in a dry, some in a moist at- 
mosphere, some at a high, some at a low elevation, some in inland locali- 
ties, some by the seaside, some on one side of a street of which the opposite 
side is innocuous to them. But most find themselves better in London or 
other large towns than they are in the country ; and, as a rule, a moist 
air is more suitable for them than a dry air, a low site better than an ele- 
vated site. Among the conditions which may be supposed to act indirectly 
are the ingestion of certain articles of diet (which, however, differ so much 
for different asthmatics that it would be useless to quote examples), disten- 
sion of the stomach, constipation, disease of the brain, and violent emo- 
tions. Dr. Salter considers that when particular articles of food cause 
asthmatic attacks, they act after absorption, and hence directly on the 
mucous membrane of the bronchial tubes. 

Symptoms and progress — The asthmatic paroxysm usually comes on 
without warning. In some cases, however, it is preceded for a shorter or 
longer time by premonitory symptoms, which are different for different 
cases, but mostly uniform for each case. These are, sometimes abnormal 
buoyancy of spirits, sometimes mental depression, sometimes drowsiness, 
but most frequently a slight degree of the asthmatic state, manifesting 
itself by tendency to wheeze, constriction across the chest, sense of flatu- 
lence, alteration of carriage, and the like. Among the occasional ear- 
lier phenomena of asthma are a tendency to pass an abundance of pale 
limpid urine, and (as Dr. Salter points out) a peculiar troublesome itching 
under the chin, not relieved by scratching. 



ASTHMA. 



429 



The attack may come on at any hour, but is almost always uniform, or 
nearly so, as to the time of its supervention in each case. It sometimes 
occurs an hour or two after dinner, sometimes as soon as the patient lies 
down in bed, but in the great majority of cases between two and four 
o'clock in the morning, probably after the patient has had a comfortable 
sleep. There is no doubt (as Dr. Salter observes) that the forenoon is in 
every respect the most favorable time for asthmatics ; their attacks least 
frequently commence then, and when on them are apt at that time to un- 
dergo some remission. 

The symptoms of the asthmatic paroxysm are mainly those of intense 
dyspnoea. The patient is probably roused from sleep with the symptoms 
full upon him ; or else, after a certain time of discomfort passed between 
sleeping and waking in battling with his augmenting dyspnoea, wakes to 
the full consciousness of his condition. He is then compelled to rise from 
his bed — baring his chest and throwing aside everything that hampers 
his respiratory movements — in all the agony of impending suffocation. 
The phenomena of the fully developed paroxysm are, for the most part, as 
follows: — The sense of suffocation is terrible ; the patient's whole energies 
are devoted to the performance of the respiratory acts ; his breathing is 
not rapid, often, indeed, slower than natural ; but it is effected with the 
most violent efforts ; his mouth is open, his nostrils dilated, his shoulders 
elevated, his head thrown back ; the respiratory muscles harden and stand 
out, and he places himself in some constrained position which gives them 
leverage — standing or sitting with his elbows resting on the table or some 
other elevated ledge and his head buried in his hands, or grasping some 
unyielding object, generally above his head ; he places himself even in 
the depth of winter at the open window. The expression of his face 
is one of intense anxiety ; the lines are strongly pronounced ; his eyes are 
congested and protruding, his surface pale and ghastly, or livid; copious 
perspirations break out upon his face, head, and trunk, while his arms 
and legs, and especially his hands and feet, become cold ; the pulse is 
rapid, small, feeble, and sometimes irregular. The dyspnoea is peculiar: 
inspiration is comparatively short, expiration greatly prolonged, and both 
are attended with loud wheezing ; no interval exists between expiration 
and the following inspiration. The chest cavity is greatly expanded ; it is 
large and rounded from elevation of the ribs, elongated from depression of 
the diaphragm ; and this expansion is maintained even at the end of ex- 
piration — the fact being that the chest is abnormally distended with air, 
and that the powerful action of the respiratory muscles effects very little 
movement in its parietes, and consequently very little interchange of air. Dr. 
Salter points out, indeed, that this over-distension of the chest begins to 
take place even before the appearance of manifest dyspnoeal symptoms, 
and that the descent of the diaphragm even at this early stage causes 
measurable enlargement of the upper region of the abdomen, which may 
easily be, and often is, mistaken for abdominal flatulence. On percussion 
the chest is probably abnormally resonant, and the cardiac dulness is dimin- 
ished in area or effaced. On auscultation there is usually total absence of 
normal respiratory murmur, but in its place general sibilant rhonchus in 
all its varieties. The patient speaks with difficulty, bringing his words 
out pantingly one by one. There is usually no cough, at all events none 
at the beginning of the attack. 

The duration of the paroxysm varies from a few minutes to several 
weeks — most frequently it is two or three days, or it commences at the 



430 



DISEASES OF THE RESPIRATORY ORGANS. 



usual time and subsides in the course of the the following day. When 
the attack is much prolonged, it is generally made up of a series of shorter 
attacks, separated from one another by periods of more or less perfect re- 
mission. Its disappearance is attended with the gradual subsidence of 
the asthmatic phenomena, and the supervention of cough. This is at first 
dry ; but by degrees crepitation replaces wheezing, and the cough is then 
accompanied by the expectoration of mucus in small transparent pearly 
pellets, and occasionally by sputa slightly streaked with blood. Frequently, 
and this is especially the case after short attacks, recovery is rapid and 
complete. In other cases, the patient suffers subsequently for a longer or 
shorter time from tightness at the chest and dyspnoea, with more or less 
cough and expectoration. 

Asthmatic attacks have a tendency not only to recur, but in a large 
number of cases to distinct periodicity of recurrence. Thus in some cases 
they come on weekly, monthly, yearly, or at other intervals which the 
patient's experience enables him to foretell. In most cases, however, their 
recurrence is due to the more or less regular recurrence of those extrinsic 
causes which determine the attack : such, for example, as the assumption 
of the recumbent posture, variations in diet, change of residence, and 
change of season. 

The prognosis of asthma is very uncertain. In many cases, especially 
if it commence in infancy, it disappears during the period of adult life. 
When it comes on at an advanced age it is probably always permanent. 
Indeed, in a large proportion of cases, whatever the time of its commence- 
ment, its duration is life-long. But then the affection usually undergoes 
some change of type with the advance of years. This depends in great 
measure on the slow supervention of organic lesions. Thus, especially if 
the attacks be frequent and severe, the lungs are apt after a time to become 
emphysematous, and the right side of the heart hypertrophous — conditions 
which are usually attended with diminution in the severity of the actual 
attacks of asthma, but the development of permanent shortness of breath 
during the intervals between them, and other symptoms of emphysema 
and chronic bronchitis. Further, asthmatic patients frequently acquire 
an almost characteristic physical conformation. They are, as a rule, ema- 
ciated, with thin furrowed cheeks, high shoulders, body bent forwards, 
head thrown back, and misshapen chest — the upper part being dilated, the 
lower compressed, especially in the lateral direction. 

Dr. Salter divides asthma into idiopathic or primary, and symptomatic 
or secondary. The former is the affection which we have endeavored to 
describe. But symptoms identical in the main with those of asthma super- 
vene secondarily on other affections, especially dyspepsia, bronchitis, and 
heart disease, and are termed by him peptic, bronchitic, and cardiac 
respectively. 

Pathology The extreme rarity with which death takes place in 

uncomplicated asthma renders the investigation of the pathology of the 
disease difficult. There is ample proof, however, that it occurs quite 
independently of organic lesions of the lungs, heart, or other important 
organs, and that it is therefore a so-called 'functional' disease. Jndeed, 
the observations of Drs. Gairdner and Salter establish, almost beyond the 
possibility of doubt, that its symptoms are essentially dependent on spas- 
modic contraction of the muscular tissue of the bronchial tubes, and con- 
sequent narrowing of their calibre. It is easy to see that such contraction 
is ample to explain not only the dyspnoeal symptoms, but the auscultatory 



HAY- ASTHMA. 



431 



peculiarities, the sudden accession and sudden subsidence of each attack, 
and even the organic changes which in some cases ensue. At the same 
time it may be worth while to notice that there is something in the persist- 
ence and singular periodicity of the disease, and in the fact of the frequent 
dependence of the paroxysm on a variety of apparently trivial conditions, 
to remind us of the skin affections known as urticaria evanida and facti- 
tious urticaria, and that urticaria-like swelling of the mucous membrane 
might equally explain the temporary contraction of the bronchial tubes. 
Under any view, however, the bronchial affection must be referred to the 
operation of the nervous system, possibly excited by reflection from the 
bronchial surface. 

Treatment In the treatment of the asthmatic paroxysm all ligatures 

and other impediments to respiration should be loosened, and the patient 
should be made to assume such a position as will enable him to use his 
respiratory muscles to advantage. Further, any gastric or other derange- 
ment under which he may be suffering, or any condition which may be 
supposed to have induced or favored the attack should, as far as possible, 
be at once remedied or removed. Many drugs are more of less beneficial. 
Among these may be enumerated tartar emetic and ipecacuanha in emetic 
doses : tobacco, given so as to produce its characteristic depressing effects, 
or smoked in the usual way : lobelia inflata also so given, in large and 
frequently repeated doses, as to cause great depression ; datura stramo- 
nium or datura tatula, used either by inhalation or in the form of tinc- 
ture or extract ; belladonna, conium, hyoscyamus, and opium (the last, 
according to Dr. Salter, is injurious in uncomplicated asthma, benefiting 
those cases only in which there is associated bronchitis) ; alcohol, ether, 
strong coffee ; nitre paper burnt in the apartment; and chloroform. The 
effects of chloroform are marvellous, but unfortunately they are for the 
most part only temporary. 

The principles by which the general treatment of an asthmatic patient 
should be regulated are sufficiently simple; they consist in the avoidance 
of all the causes which in his case are known to induce an attack ; the 
selection of that locality for residence which experience has shown to be 
most suitable for his case ; and the maintenance of his general health by 
wholesome food, and the adoption of habits and an employment compatible 
with health. If the patient have not yet learnt by experience what he 
can do and what he cannot do with impunity, the rules which we lay down 
for his guidance must be such as are in accordance with what we know of 
the general peculiarities of the disease. 



XXI. HAY-ASTHMA. {Hay-fever.) 

Definition — This term has been applied to a peculiar catarrhal affec- 
tion coming on in this country during the months of May, June, and July, 
and commonly referred to the emanations from various flowering grasses, 
or new-mown hay. 

Causation. — A small number of persons only are susceptible, but these 
suffer annually at the season specified, unless they take precautions against 
the inhalation of the irritating influence, by either remaining indoors, be- 
taking themselves to some large town, removing to the sea-side, or taking 



432 



DISEASES OF THE RESPIRATORY ORGANS. 



a sea-voyage. The tendency to hay-asthma seems hereditary. Condi- 
tions closely resembling it are produced in some persons by the smell of 
ipecacuanha or other vegetable effluvia, or by emanations from various 
animals, such as cats, rabbits, and dogs. The precise cause of hay-asthma 
has been a matter of discussion. Helmholtz, a few years ago, discover- 
ing, in the mucus discharged from the irritated mucous membrane, lowly 
vegetable organisms, attributed the disease to their influence. Dr. Elliot- 
son, many years since, suggested pollen as its cause. And Mr. Blackley, 
himself a sufferer, has recently published a work on hay-asthma, in which, 
by a series of most careful researches, he appears to have proved the accu- 
racy of Dr. Elliotson's suggestion. He comes to the conclusion that the 
effects of pollen are partly mechanical, partly chemical, and that it acts 
locally : — if applied to the eye causing conjunctivitis ; if to the nose 
coryza ; if by inhalation to the bronchial tubes asthmatic symptoms. 

Symptoms and progress — The symptoms of hay-asthma are in the main 
those of violent catarrh ; — namely itching, congestion and swelling of the 
conjunctiva; and eyelids, and watering of the eyes ; itching, congestion, 
tumefaction, and copious discharge from the nostrils, attended with much 
sneezing ; great irritation in the throat, fauces, and soft palate ; tightness 
at the chest, and dyspnoea, with cough and expectoration. The symptoms 
vary in their severity, and generally become aggravated towards the mid- 
dle and end of June. Jn the first instance, and in mild attacks, the con- 
junctival and nasal mucous surfaces alone may suffer. The symptoms are 
in all cases liable to more or less regular exacerbations. 

Treatment. — The most obvious and effectual method of treatment is the 
avoidance of the cause of the disease ; and, indeed, many sufferers have 
learnt by bitter experience entirely to shun the country and all proximity 
to grass fields and new hay during the dangerous season. For those who 
are compelled to expose themselves, the use of a respirator, made, as Mr. 
Blackley suggests, with six or eight folds of crape or a double fold of cam- 
bric, will prove of considerable advantage. Helmholtz has recommended 
(and his recommendations appear to have been followed with more or less 
success) the washing out of the nostrils and throat with a weak solution 
of quinine, by means of a pipette or nose-douche. Other medicines which 
have been tried with reputed success are the tincture of nux vomica in 
ten-grain doses, tincture of aconite, liquor arsenicalis, hydrocyanic acid, 
and the smoking of tobacco or stramonium. 



[AUTUMNAL CATARRH. 

Under this name Dr. Morrill Wyman, of Boston, has described a dis- 
ease peculiar, so far as is known, to the United States, and having many 
points of resemblance to hay-asthma, but differing from this in occurring 
towards the close, instead of at the beginning, of summer, and in the 
greater intensity of most of its symptoms, especially those presented by the 
eyes, nose, and throat. The cough is also apt to be more severe and 
paroxysmal, while attacks of dyspnoea are more frequent. It is met with 
throughout the New England, Middle, and some of the Western States, 
with the exception of a part of the White Mountains country in New 
Hampshire, and of the elevated plateaux of the Alleghanies in New York 



AUTUMNAL CATARRH. 



433 



and Pennsylvania, the inhabitants of which seem to enjoy an entire im- 
munity from it. It apparently does not extend into the region lying west 
of the Mississippi, or into the Southern States; nor is it found in the 
greater part of Canada. The attacks recur annually at about the same 
time, beginning generally on from the 18th to the 25th of August, and 
continuing until the occurrence of the first severe frost, when they usually 
abruptly cease. In fact, such is the regularity of their appearance, that 
patients frequently know accurately the day, and it is said, in some cases 
even the hour, when to expect them. 

The sea air does not afford the same relief as it does in hay-asthma, and 
the sufferer, beyond being invigorated by it, and thus rendered better able 
to withstand the debilitating effects of the disease, is not benefited by a 
residence on the coast. Immediate improvement will often, on the other 
hand, follow his removal to one of the localities where the disease is not 
met with, and attacks may be wholly avoided by passing the summer in 
such a place. 

Causation The precise cause of this disease has never been positively 

ascertained. There is good reason for believing that the attacks are pro- 
duced, in some cases at least, by the irritating effects of the pollen of the 
Roman wormwood (Ambrosia artemisicefolid) upon the respiratory mucous 
membrane. Exacerbations are caused by the inhalation of dust or smoke, 
by exposure to a strong light, and by the smell of certain fruits and 
flowers. A hereditary predisposition to the disease may be traced in many 
of the cases. 

Symptoms. — These so closely resemble those presented by hay-asthma 
that it is unnecessary to give them in detail. 

Treatment — Whenever the patient's means will allow it he should at once 
seek relief, either by removal to a place in the United States where the 
disease does not occur, or by going to Europe. Patients rarely suffer 
while actually on the ocean ; a sea voyage may therefore be prescribed in 
some cases with advantage. Among the remedies which have been em- 
ployed with asserted advantage are quinia, arsenic, strychnia, bromide 
and iodide of potassium, and hydrocyanic acid ; but medicines evidently 
exert little or no influence over the course of the disease.] 



28 



434 



DISEASES OF THE VASCULAR ORGANS. 



CHAPTER IY. 

DISEASES OF THE VASCULAR ORGANS. 

The vascular system comprises the heart, arteries, veins, and capillaries ; 
the lymphatic glands and vessels, together with certain ductless glands ; 
and the blood with its tributary fluids. Of all the parts here enumerated 
the heart, the centre and presiding genius of the system, is by far the most 
important, both physiologically and on pathological grounds ; and to the 
morbid conditions of the heart, therefore, we shall first direct attention. 



Section I. — DISEASES OF THE HEART. 
I. INTRODUCTORY REMARKS. 

A. Anatomy and Anatomical Relations of the Heart. 

1. Dimensions of heart. — The heart has been estimated somewhat roughly, 
yet not inaptly, to equal in size its owner's fist. It enlarges with the growth 
of the body until growth ceases, and then continues to enlarge, though 
slowly, during the remainder of life. Its average weight in the adult male 
varies between ten and eleven ounces ; in the adult female is about nine 
ounces. The capacities of its several cavities are probably nearly equal ; 
the auricles, however, are believed to be somewhat less capacious than the 
ventricles, and the left cavities than the right. The ventricles of the adult 
heart have, each, a capacity which has been variously estimated at from 
two to five ounces. The mean capacity is probably three ounces. The 
thickness of the cardiac walls presents considerable differences : those of 
the right auricle measure on the average about a line ; those of the left 
auricle about a line and a half ; those of the right ventricle (at the base 
where they are thickest) very nearly two lines ; and those of the left ven- 
tricle (midway between the base and apex, where their thickness is great- 
est) rather more than five lines. Of the cardiac orifices the auriculo- 
ventricular are larger than the arterial, and those of the right side larger 
than those of the left side to which they respectively correspond. The 
following table gives Dr. Peacock's circumferential measurements : — 

Males. Females. 
Inches. Inches. 

Auriculo-ventricular . | * * ' * 4 ' 74 



Arterial | P 



Aortic . . . 3-15 3'02 



2. Relations of heart to pericardium The heart, which occupies the 

middle mediastinum, is contained within the fibrous pericardium — a some- 
what conical bag, of which the base corresponds to a portion of the central 



ANATOMICAL RELATIONS OF THE HEART. 



435 



tendon of the diaphragm, the apex to the ascending arch of the aorta, the 
pulmonary artery, and superior cava; with the parietes of which vessels, 
as also with those of the pulmonary veins and inferior cava, its librous 
tissue blends. The serous pericardium, on the one hand, lines the fibrous 
pericardium in its whole extent ; on the other hand, closely invests the 
heart, forms a tubular sheath around the trunk of the pulmonary artery 
and the ascending aorta, furnishes incomplete investments to the proximal 
extremities of the pulmonary veins and venae cavae, and is reflected thence 
to become continuous with the parietal lamina. The pericardial cavity 
extends from the upper margin of the second costal cartilage above (at 
which point the ascending arch ends), to the central tendon of the dia- 
phragm below. 

3. Relations of heart to chest-walls and surrounding organs The 

heart occupies an oblique position. Its base, which includes the points of 
attachment of all the large arteries and veins, and is formed mainly by 
the auricles, is directed upwards, backwards, and to the right, and extends 
vertically from the fourth to the eighth dorsal vertebra. Its apex points 
in the opposite direction, namely, downwards, forwards, and to the left, 
and usually impinges between the fifth and sixth costal cartilages, a little 
internal to a line drawn vertically through the nipple. The position of 
the apex varies, however, a little in different healthy persons, and differs 
a little also with change of posture, and with the respiratory movements. 
If it beat in the fifth interspace during recumbency, it probably beats 
against the sixth cartilage when the upright position is assumed. The 
anterior aspect of the heart, which also faces upwards, is formed below 
and to the right by the right auricular appendage and right ventricle; 
above and to the left by the left auricular appendage and left ventricle. 
The greater part of this aspect, however, is constituted by the right ven- 
tricle. The posterior aspect, which is also directed downwards, and rests 
mainly on the diaphragm, consists exclusively of the two ventricles — the 
left ventricle forming by far its larger proportion. About two-thirds of 
the heart are situated to the left of the mesial plane of the body, the re- 
mainder to the right. 

The relations of the heart and great vessels to the surface of the chest 
are important. The outer margin of the left ventricle extends from the 
left second intercostal space (midway between the osseous ribs and ster- 
num) outwards and downwards to the apex in the left fifth interspace. 
The outer margin of the right ventricle commences at the sternal end of 
the right fifth costal cartilage, and passes thence downwards and to the 
left to meet the former line in the apex, The left auricular appendage 
slightly overlaps the upper edge of the left ventricle, making its appearance 
in the lower part of the second intercostal space. The right auricular ap- 
pendage extends from about the same level above (commencing, however, 
at the mesial line of the sternum) downwards to the point at which the 
margin of the right ventricle begins. Between these points it presents a 
semilunar form — the one limiting line taking a nearly straight course be- 
neath the sternum, the other limiting line being convex, and extending 
in the third and fourth interspaces half-way from the sternum to the osse- 
ous ribs. 

Of the valves, the pulmonic is the highest and most superficial; it is 
situated immediately to the left of the sternum — perhaps a little beneath 
it — in the second interspace; the aortic, which is deeper seated than the 
pulmonic, and indeed partly overlapped by it, is subjacent to the junction 



436 



DISEASES OF THE VASCULAR ORGANS. 



of the left third cartilage with the sternum and to the adjoining half of 
the sternum ; the tricuspid lies beneath the sternum, its centre midway 
between the sternal ends of the fourth costal cartilages ; the mitral, which 
lies deepest of all the valves, is situated behind the pulmonic and aortic, 
and on a lower level than they, its central point probably corresponding 
to the left third interspace, a little external to the sternum. 

A small portion only of the heart is in actual contact with the anterior 
walls of the chest, the remainder being separated from them by the thin 
edges of the lungs. In ordinary tranquil inspiration the lungs almost meet 
in the mesial line of the sternum from above down to a point midway be- 
tween the sternal ends of the fourth costal cartilages. From this point 
the edge of the right lung still continues vertically downwards, while that 
of the left retreats to the junction of the left fifth cartilage and rib, where 
it forms a notch just before its termination in the basal edge. A triangular 
interval is thus produced, situated wholly to the left of the mesial line of 
the sternum, bounded on either side by the edges of the lungs, and below 
by the diaphragm, to which the left lobe of the liver is immediately sub- 
jacent. In the outer angle of this space a small portion of the apex of the 
left ventricle becomes superficial, the rest of the triangle being occupied 
by the right ventricle. 

Laterally, the heart is bounded by the lungs, from each of which it is 
separated by both pleura and pericardium ; behind, it is limited by the 
posterior mediastinum, with the roots of the lungs above, and the cesophagus 
and thoracic aorta in its whole extent, separating it from the vertebrae ; 
below, it lies on the diaphragm, which divides it from the liver, and partly, 
to the extreme left, from the stomach. Above, it is continued into the 
large vessels, namely the pulmonary artery, aorta, and vena cava. 

The ascending aortic arch, covered at first by the pulmonary arterial 
trunk, and then by the right auricular appendage, passes upwards and to 
the right beneath the sternum, and extends for about a quarter of an inch 
beyond the edge of the sternum into the right second and first intercostal 
spaces. The superior cava extends half an inch further in the same direc- 
tion. The transverse arch corresponds as nearly as possible to the lower 
half of the manubrium. The pulmonary artery passes between the two 
auricular appendages upwards, backwards, and to the left, and, having 
crossed the commencement of the aorta, lies to the left of that vessel, be- 
coming superficial at the inner part of the left second interspace, just before 
it retreats under the aortic arch to divide into its two branches. 

B. Physiology of the Heart. 

1. Action of heart — The function of the heart is to maintain the circu- 
lation of the blood in both the systemic and the pulmonary vessels. To 
effect this it undergoes a series of alternately active and passive movements, 
which are rhythmical and follow one another with greater or less rapidity. 
To commence with the ventricular contraction : The ventricles, already 
distended with the blood transmitted to them from their respective auricles, 
contract suddenly and actively, propelling their contents into the aorta 
and pulmonary artery respectively, and causing at the same time the closure 
of the auriculo-ventricular valves. Whilst this contraction is in progress 
the auricles, which were contracted at the moment of its commencement, 
gradually dilate, and by the time the ventricles have got completely empty, 
have attained their full dimensions and are full of blood. The contracted 



PHYSIOLOGY OF THE HEART. 437 

ventricles now relax and in their turn expand, the arterial valves close, 
and the auriculo-ventricular valves open and allow of the flow of blood 
through the still dilated auricles into the ventricles. Soon the passively 
dilating ventricles are almost filled, when suddenly the hitherto torpid 
auricles contract, adding their contents to those of the ventricles which 
thus become distended. Immediately after the contraction of the auricles, 
and indeed almost by a continuous peristaltic action, the contraction of the 
ventricles takes place, and the cycle of events above described recurs. 

It is important to add, in the first place, that the actions of the two sides 
of the heart are, as nearly as possible, synchronous ; and in the second 
that the closure of the auriculo-ventricular valves takes place at the begin- 
ning of the cardiac systole, that of the arterial valves at the beginning of 
the cardiac diastole. It must be added, too, that the force with which 
the ventricles act is always exactly equal to the resistance which they 
overcome; that (other tilings being equal) contraction of the arterioles 
calls for increase of cardiac exertion, their dilatation for its diminution ; 
and that (again other things being equal) increased quickness of the ven- 
tricular systole implies greatly augmented exercise of cardiac force, and 
conversely. 

The contraction of the heart is attended with distinct pulsation in the 
precordial region. The area over which this extends varies somewhat 
with the form of the chest, and considerably with different degrees of 
thinness or plumpness of the thoracic parietes. Generally it is limited to 
the apex, where it is always most intense, and covers not more than a 
square inch of surface. A certain amount of epigastric pulsation, due to 
the movements of the right ventricle, is compatible with health. 

2. Sounds of heart The contraction and dilatation of the ventricles 

are each attended with a characteristic sound, which marks the commence- 
ment of the act, and is followed by a short interval of silence. These 
constitute respectively the first and second sounds of the heart. The 
first, or systolic sound, varies in character in different persons ; it is, how- 
ever, always deeper in tone and longer in duration than the other ; it is 
' also more or less compact, beginning and ending with a certain amount 
of abruptness. It is audible over the whole of the cardiac region, but is 
most pronounced over the apex of the left ventricle. The second, or dia- 
stolic sound, is short, perhaps half the length of the first, sharp, and some- 
what ringing. It is heard with greatest distinctness at the base of the 
heart, and more especially in the right second interspace immediately 
adjoining the sternum. The loudness of the sounds and the extent of 
surface over which they are respectively audible are subject to great 
variety. 

Many causes have been assigned for the cardiac sounds. There is, how- 
ever, now no doubt that the second sound is due to the sudden closure of 
the arterial valves which takes place at the commencement of the ventric- 
ular diastole ; and there is little doubt that the first sound is mainly attri- 
butable to the generally less sudden closure of the auriculo-ventricular 
valves which attends the commencement of the ventricular systole. But 
it is pretty certain that the first sound is reinforced by that clue to the 
contraction of the muscular tissue of the cardiac walls. For the most 
part, as has been already pointed out, the two sides of the heart act in 
unison ; and hence the two arterial valves usually concur in the production 
of the second sound, the two auriculo-ventricular in that of the first ; but, 
inasmuch as the action of the left side of the heart is far more powerful 



438 



DISEASES OF THE VASCULAR ORGANS. 



than that of the right, the valves of that side take the chief share in caus- 
ing the cardiac sounds. It is owing to this fact that the second sound 
is usually loudest towards the base of the heart over the right half of the 
sternum, and that the first is usually most obvious where the left ven- 
tricle becomes superficial, namely, at the apex. When the sides do not 
act in perfect unison, a more or less obvious reduplication of the cardiac 
sounds takes place. 

3. Pulse The intermittent injection of blood from the heart into the 

arteries produces the phenomenon known as the pulse. The beats of the 
pulse correspond, as a rule, in number and rhythm to the contractions of 
the cardiac ventricles ; and, like them, follow one another, for the most 
part, with remarkable regularity ; although liable, in different persons, and 
under different circumstances, to present great variations as to rate and 
force, and always presenting slight relative increase of rate and force dur- 
ing inspiration, and slight relative decrease during expiration. The char- 
acter of the pulse, although depending mainly upon the action of the 
heart, is largely modified by the condition of the arteries in which it 
occurs, and by that of the capillary arteries and capillaries, and of the 
venous system beyond. During the whole period of the contraction of 
the left ventricle its contents are being propelled into the aorta ; and the 
force which is thus exerted within the arteries is expended, partly in 
driving the blood already within the vessels onwards, partly in stretching 
the elastic walls of the arteries. The consequent arterial tension attains 
its maximum with more or less rapidity, and then diminishes before the 
systolic action is completed. As soon as, with the cessation of the systole, 
the propulsion of blood into the aorta ceases, the distended arteries con- 
tract upon the blood within them, still propelling it onwards, but with 
gradually diminishing force, until they have attained their former calibre 
or until their contraction is interrupted by the next cardiac systole. The 
period here adverted to corresponds to the ventricular diastole. If the 
pulse presented no other elements than those immediately due to the phe- 
nomena which have just been considered — namely, the systolic distension 
of the artery, on the one hand, and its diastolic collapse on the other, the 
sphygmographic trace of the pulse would have some such form as that 
represented in fig. 1. 

FU,.7. 



There would be a more or less sudden rise, presenting a rounded summit, 
the highest point of which would correspond to the moment of highest 
arterial tension ; and this would be followed by a more or less gradual fall. 
But, for the most part, the sphygmographic tracing displays other elements 
besides these. In the first place, the line of ascent is usually prolonged 
vertically upwards and then suddenly falls, forming a very acute angle, 
before it merges in the convex summit above indicated ; and in the second 
place, the line of diastolic collapse is, for the most part, interrupted at its 
commencement by a more or less distinct rise, and frequently, after a short 
interval, by a further and less distinctly marked wave, or a diminishing 




PULSE. 



439 



series of waves. The typically complete tracing would thus present not 
less than four successive waves, of which at least two would correspond 
to the systole of the heart, and at least two to the diastole. The first of 
these waves, which is known as the 'primary or percussion wave, is gener- 
ally attributed, not to any actual addition to the quantity of blood which 
the artery presenting it already contains, but to the impulse which is sup- 
posed to be transmitted along that blood by the shock of the commencing 
systole ; and is supposed to precede by a scarcely appreciable interval the 
secondary or tidal wave which follows it. Dr. Galabin, however, shows 
that this explanation is incorrect, and 4 that the percussion and tidal waves 
form in the artery but one wave, and are only separated by the sphygmo- 
graph. Owing,' he says, 4 to the inertia of the long lever it is carried up 
a little too high, and when in falling it meets the true arterial wave it is 
again tossed up, and thus forms the tidal wave.' The third, or the di- 
crotic wave, has, like the first, been variously explained. It has been 
attributed by many to the shock of the sudden closure of the aortic valves, 
an opinion in which Dr. Galabin concurs ; and again to the recoil of the 
hitherto distended arteries. But the cause is probably that which Dr. 





// 


c 










I 




e 


f 





a, Primary or percussion wave ; ft, secondary or tidal wave : c, dicrotic wave ; 
d, fourth, wave ; e, aortic notch ; f g. duration of cardiac systole ; 
g h, duration of cardiac diastole. 

The dotted line represents the tracing- which would he drawn if the instrument 
followed the movement of the artery with perfect accuracy. 

Copied, with slight modification, from Dr. Galahin's diagram. — Thesis for the 
Degree of M.D., Cantab., 1873. 

Sanderson assigns for it. He points out that as the wave due to the injec- 
tion of the ventricular contents into the aorta takes a certain time to reach 
the capillary arteries, and as hence the period of greatest movement in 
the latter vessels must take place distinctly later than that in the aorta, 
so the subsidence of this wave and the period of comparative rest which 
marks the end of systole and the whole of diastole is likewise delayed in 
transmission to the peripheral vessels ; and that consequently there is a 
moment at which, while the blood is almost stagnant in the aorta, it is 
still flowing rapidly through the minuter vessels, and a later moment at 
which the blood in the capillaries also becomes comparatively quiescent. 
But this arrest in the capillaries, accompanied as it is by the contraction 
of the elastic arterial coat upon the diminished contents of the vessels, pro- 
duces a virtual distension and a sudden increase of pressure throughout the 
arterial system. The dicrotic wave is the expression of this arterial ten- 
sion. The fourth wave has probably, as Dr. Galabin considers, the same 
relation to the dicrotic wave as the tidal to the percussion wave. 

Let us now briefly consider the significance in the order of their occur- 
rence of the more important of the several factors of the pulse-tracing 
which have been enumerated. The initial rise will necessarily be largely 



440 



DISEASES OF THE VASCULAR ORGANS. 



determined as to its amplitude by the suddenness and violence of the car- 
diac systole; but will obviously be also influenced more or less consider- 
ably by the condition of the arteries — flaccidity aiding it; tension, on the 
other hand, opposing it. The presence of the tidal wave as a distinct 
event depends mainly upon the duration of the tension of the arteries due 
to the ventricular systole. If the tension be of short duration the percus- 
sion wave falls rapidly and continuously until its fall is arrested by the 
dicrotic rise; if it be long sustained, then the second rise becomes devel- 
oped, varying in its form according to the condition of the artery. The 
breadth of the combined summits of these two curves is, therefore, a mea- 
sure of the duration of the tension here adverted to ; the breadth of their 
bases, as determined by a horizontal line drawn from the commencement 
of the systolic rise to the end of the systolic fall, is a measure of the dura- 
tion of the cardiac systole ; and the lowest point of the notch which sepa- 
rates the tidal from the dicrotic wave indicates the moment of closure of 
the aortic valve. The third rise (the dicrotic wave) may be regarded as 
a measure of the completeness of the check which the systolic wave expe- 
riences in the smaller vessels during the diastolic period, and is indicative, 
therefore, either of comparative feebleness of the heart's action or of high 
tension of the venous relatively to that of the arterial system. The dura- 
tion of the diastolic period is measured by the horizontal line which may 
be drawn from the aortic notch to the commencement of the next systolic 
ascent. 

The character of the pulse varies in health, not only in different indi- 
viduals, but in the same person at different times and under different cir- 
cumstances. It may be frequent or infrequent, conditions which may be 
recognized as well by the finger and the watch as by any more complicated 
machinery. It may be long or short. These terms apply, not to the whole 
interval between the commencement of one pulsation and that of the pul- 
sation which next follows (for in that case they would be synonymous with 
'infrequent' and ' frequent' respectively) but to the duration of the systolic 
wave. These qualities may be roughly recognized by the finger, but are 
demonstrated with accuracy only by the sphygmographic tracing. It 
should be noted here that when a pulse becomes increased in frequency, 
this increase is due mainly to curtailment of the diastolic period. Jt may 
be large or small. These terms are employed somewhat loosely ; the 
former should perhaps be used of that state in which a considerable volume 
of blood is propelled into the arteries at each systole, and the latter of the 
converse condition. We are apt, however, to term that also a large pulse 
which occurs in dilated arteries, such as those of elderly persons, and that 
a small pulse in which the arteries are simply contracted. These different 
forms of largeness or smallness are often combined, and are indicated re- 
spectively in the sphygmographic trace by relative amplitude of the systolic 
waves. The pulse may be strong or weak, or in other words hard or soft. 
The former resists compression by the finger, the latter is easily obliterated 
by it. The best test, however, of strength of pulse is again the sphygmo- 
graph, by means of which the amount of pressure necessary to procure 
obliteration can be estimated with some degree of accuracy. It may be 
added that when there is high arterial tension it is necessary to use con- 
siderable pressure in order thoroughly to develop the characteristic tracing. 



MECHANICAL AND STRUCTURAL DERANGEMENTS. 441 



C. Pathology of the Heart. 

The heart and structures associated with it may, as is the case with all 
other organs, become the seat of inflammatory or other process, which will 
then produce the local and general symptoms commonly belonging to such 
processes. But the heart is an instrument of extreme delicacy, and is 
liable, under the influence of these and other conditions, to have its me- 
chanism more or less seriously deranged. Its derangements, which may 
be structural or functional, or both combined, produce various local and 
remote or general consequences which are the characteristic symptoms or 
sequelae of heart disease. We propose to consider these derangements and 
their consequences briefly, apart from the intimate nature of the patho- 
logical lesions from which they spring, and apart also from the special 
symptoms due to the specific nature of these lesions. 

1. Mechanical and Structural Derangements. 

The local conditions which interfere with the healthy action of the heart 
may either be seated external to the organ ; or involve its muscular walls ; 
or be connected with its valves ; or be situated within its cavities. It may 
of course happen that two or more of such lesions are associated. 

a. Conditions external to the heart — Simple displacement of the heart 
is met with under many different circumstances. Occasionally, in com- 
pany with the other viscera of the chest and abdomen, it is found trans- 
posed. Ascites or abdominal tumors may displace its apex upwards and 
to the left ; aneurisms of the arch, and other tumors of the upper part of 
the chest or posterior mediastinum, may cause it to descend. Serous or 
other effusions into either pleura commonly push it over towards the op- 
posite side ; while the contraction of the lung and side which so often 
attends cirrhosis and the absorption of pleuritic fluid tends to attract it 
more and more towards the affected side. It may be observed that the 
displacements which result from the last conditions are generally much 
more noticeable when they take place towards the right than when they 
take place towards the left side ; in distension of the left pleura it is not 
uncommon to find the heart beating wholly between the right nipple and 
right edge of the sternum. In spinal curvature, also, the position of the 
heart is often much modified, being then greatly determined by the rela- 
tive sizes of the two halves of the chest and by the degree and form of the 
curvature ; sometimes it lies wholly to the right of the sternum, sometimes 
beneath it. Occasionally, when the patient is markedly pigeon-breasted, 
the heart occupies the whole of the space which lies between the two nip- 
ples. The most remarkable displacements of the heart, however, are those 
which result from the growth of intrathoracic tumors. In such cases the 
apex of the organ has been detected beating in the right axilla. 

In reference to displacements, it is important to recollect, that the base 
of the heart is comparatively firmly fixed above and posteriorly ; and that, 
although no doubt the parts contained in the posterior mediastinum, and 
the base of the heart which is incorporated with them, are often displaced 
to a greater or less extent, it is that portion of the heart which lies free in 
the pericardium that is chiefly apt to suffer in this respect, and is often the 
only part so affected— the free or ventricular portion of the organ moving 
at its base on a pivot. 

Affections of the pericardium are much more serious causes of cardiac 



U2 



DISEASES OF THE VASCULAR ORGANS. 



disturbance than those just considered. They act mainly by compressing 
the heart and thus interfering with the efficient performance of its duties. 
The affections here specialty adverted to are such as are attended with 
effusion of fluid and those in which fibrous and other forms of solid mate- 
rial accumulate. The effusion may be merely dropsical or inflammatory 
and associated with the formation of false membrane, or purulent, or hemor- 
rhagic. When fluid is poured forth into the cavity, it gradually distends 
it, enlarging it in all its dimensions, but chiefly in those situations in which 
its walls are least resistent. The cavity becomes rounded and at the same 
time elongated, especially in the upward direction along the ascending arch 
and pulmonary artery; and moreover by its distension it displaces the dia- 
phragm downwards, and the lungs laterally. At the same time the heart 
is necessarily carried with the portion of the parietal pericardium to which 
it is united backwards, and consequently away from the anterior thoracic 
walls. The quantity of fluid which accumulates within the pericardium 
is sometimes enormous. Two and even three quarts have been met with. 
The larger quantities are generally the result of chronic disease, which 
allows of the gradual distension of the pericardal cavity to a much greater 
extent than is possible in acute cases. 

b. Conditions involving the muscular ivalls — The muscular walls of 
the heart are liable to many changes. Among these we may especially 
enumerate hypertrophy and atrophy. Hypertrophy always takes place 
in response to some increased work which the heart is called upon to per- 
form, is in general compensatory, and (apart from other associated cardiac 
defects) prevents rather than promotes cardiac embarrassment. Simple 
atrophy almost invariably occurs in the course of chronic wasting disease, 
and in some sort of proportion to the concurrent atrophy of the rest of the 
organism ; and hence the dwindled heart still remains sufficiently strong 
to perform the offices required of it, and as a rule gives rise to no untoward 
symptoms. Generally associated with hypertrophy, and occasionally with 
simple atrophy, dilatation of the heart's cavities takes place. The ex- 
tremest dilatation is met with in cases of great hypertrophy ; but there is 
no necessary relation between dilatation and the amount of muscular 
tissue present. Dilatation is on the whole an evidence and cause of car- 
diac weakness. Other causes of cardiac debility are fatty and other forms 
of degeneration, inflammation, and syphilitic, sarcomatous or other infil- 
trating growths. 

c. Conditions involving the valves. — By far the most serious derange- 
ments on the whole are those connected with organic disease of the valves. 
Valvular defects may be of two kinds : — namely, obstructive (stenosis), 
that is of a nature to impede the direct flow of the blood ; or regurgitant, 
in wiiich the closure of the valves is imperfect and reflux of blood is hence 
permitted into the cavities behind them. The affections which produce 
valvular lesions are very various. We may here advert to the fact that 
the mitral valve, and still more the tricuspid, occasionally even in health 
admit of regurgitation from the ventricles into the auricles when the ven- 
tricles are over-distended with blood. In a large proportion of cases the 
lesions are due to inflammatory changes : — namely, infiltration and thick- 
ening of the tissues of the valves, the formation of beaded or warty masses 
upon their surfaces, and consequent adhesion, ulceration, or laceration. 
In many cases the valvular affection is consequent upon atheromatous and 
calcareous degeneration of the several structures connected with the valves. 



MECHANICAL AND STRUCTURAL DERANGEMENTS. 



443 



Occasionally it is the result of accidental violence, and occasionally of 
congenital malformation. Further, incompetence is sometimes due to 
dilatation of the valvular orifices — a condition which is apt to go along 
with dilatation of the ventricles, and to affect mainly the auriculo-ventri- 
cular apertures. In these cases incompetence may be aggravated by com- 
parative shortness of the carneae columnar, or chordae tendineae. We will 
briefly discuss the principal defects which the several valves are apt to 
present. 

Obstructive aortic valve disease may be due to the following causes : — 
(i.) adhesion of the several segments to one another (as a congenital defect 
it is not uncommon to find two contiguous cusps blended as far as their 
corpora arantii, the coalesced sides forming a more or less obvious vertical 
fraenum, which divides the upper aspect of the compound organ into two 
halves ; more rarely the three valves are thus blended, and when the 
blending is pretty complete they form between them a conical funnel with 
a narrow orifice in the apex which is directed upwards) : (ii.) the accumu- 
lation of inflammatory granulations : and (iii.) atheromatous or calcareous 
changes. The last are often attended with great thickening and at the 
same time great rigidity of the valves, the orifice becoming in some cases 
converted into a mere chink. 

Regurgitant aortic valve disease may depend (i.) on contraction and 
puckering of the free edges of the valves, in consequence of which they 
fail to meet ; (ii.) on ulcerative destruction or contraction of the valves 
at their angles, which allows the intermediate free edges to form pendulous 
or everted flaps ; and (iii.) on rupture or actual perforation of the curtains. 
We do not of course refer here to the fenestras so commonly observed in 
the lunulas, which, as is well known, do not in any degree impair the effi- 
ciency of the valves. 

Obstructive mitral disease may depend (i.) on cohesion of the edges of 
the curtains (this is often congenital, the valve then presenting a more or 
less funnel-like character, with its apex pointing towards the ventricle, 
and formed by a narrow, button-hole slit ; in most cases of this kind the 
valve is thickened, the chordae tendineae are short and thick, and the 
smaller branches, which radiate into the valves, apt to be more or less 
completely blended with them and with one another ; in cases of inflam- 
mation and degenerative change there is a similar tendency to the produc- 
tion of the conditions here enumerated) : (ii.) on inflammation, which 
causes thickening and at the same time granular excrescences ; and (iii.) 
on atheromatous and calcareous changes. 

Regurgitant mitral disease may depend (i.) on mere contraction of the 
free edges of the cusps ; (ii.) on shortening or rupture of the chordae ten- 
dineae ; and (iii.) on perforation of the valves. 

The morbid conditions to which the valves of the right side are liable 
are identical with those which involve the corresponding valves on the left 
side. The pulmonic and tricuspid valves are, however, comparatively 
rarely the seat of other than congenital disease. 

d. Conditions involving the contents Coagulation of blood in the heart's 

cavities not unfrequently takes place during life, more especially during 
the period in which the patient is moribund, when it must be regarded as 
a normal accompaniment of the process of dying. Older clots are also 
occasionally met with, such as the adherent rounded softening clots, or so- 
called ' polypoid concretions,' and the laminated clots which are also com- 



444 



DISEASES OF THE VASCULAR ORGANS. 



mon in sacculated aneurisms. The causes of these different varieties of 
coagula, their anatomical peculiarities, and their effects, will be discussed 
at length under the head of thrombosis and embolism. 

2. Functional Derangements. 

a. Motor derangements reveal themselves by undue feebleness or force, 
frequency or infrequency of action, by intermission or irregularity, or by 
sudden arrest of action from spasm or paralysis. Several of these are only 
exaggerations of conditions which are compatible with health. Feebleness 
of the heart's action attends most wasting diseases, and the later period of 
many febrile and other acute affections. It is common also in mitral dis- 
ease, and in some other morbid conditions of the heart. It is character- 
ized by weakness of apex beat; diminished intensity of the cardiac sounds, 
especially the first, which may be absolutely abolished ; feebleness of pulse, 
which is undulatory, thready, or markedly dicrotous, and may be imper- 
ceptible at the wrist, even while maintaining a distinctly dicrotous char- 
acter in the larger arteries ; and, lastly, a great tendency to variation in 
the rate of the pulsations under the slightest disturbing influences. In- 
creased force of cardiac action tends to take place whenever any impedi- 
ment to the flow of blood occurs either at the aortic orifice or in the course 
of the arteries, in the capillary vessels, or in the venous system. It is 
common therefore in aortic valve disease, in the presence of rigid arteries, 
and in Bright's disease. It may also occur in inflammatory disorders, 
during muscular exertion, and under the influence of nervous excitement. 
The indications of this condition are, violence and extension of the cardiac 
impulse, which is often prolonged and heaving, and may be felt in the back 
and even shake the entire body ; loudness of the cardiac sounds ; and hard- 
ness of pulse. Increased frequency of pulsation occurs under many various 
conditions ; such as nervous excitement, debility, febrile disease, and so 
on. The individual pulsations may be weak or strong, and the characters 
presented by the cardiac movements, its sounds, and the arterial pulse 
will correspond. Diminished frequency of pulsation is common in con- 
va T escence from acute disorders. It is also met with in some cerebral 
affections and in some cases of cardiac disease. The pulsations of the heart 
may mount up to 200 or even 260 in the minute, and they may fall to 20 
or even 12. The term 'palpitation' is commonly used of those conditions 
in which, under the influence of nervous excitement, the pulsations of the 
heart, arteries, or both, are painfully evident to the patient himself ; the 
beats are frequent, sudden, and violent, and the pulse often attended with 
marked dicrotism. Irregularity of the cardiac rhythm is occasionally 
observed in gout and indigestion, but is most frequently associated with 
various forms of heart disease, and especially with affections of the mitral 
valve. It is manifested by inequality of the successive pulsations, both as 
regards their force and fulness, and the length of the interval which elapses 
between them. Intermission of action is a form of irregularity which is 
mostly functional ; it is common is dyspepsia, and is occasionally a con- 
stitutional peculiarity of the patient. In intermission the general rhythm 
of the heart's action is not impaired, but at regular or irregular intervals 
a pulsation is dropped, as it were. At the wrist it is wholly absent ; on 
listening to the heart, however, the intermission is represented by an abor- 
tive throb, followed by a pulsation of greater intensity than those which 
follow next. Occasionally such abortive strokes may occur alternately 



EFFECTS OF CARDIAC DERANGEMENTS. 



445 



with effective ones, and the pulsations at the wrists be half as numerous 
as the cardiac strokes. Sudden arrest of the heart's action, and conse- 
quent death, may be caused by shock, or syncope, and is not uncommon in 
certain forms of heart disease. 

b. Abnormal sensations are frequently associated with cardiac affections. 
In palpitation the pulsations of the heart and often of the larger arteries 
are distinctly felt and complained of by the patient. When intermission 
takes place the sufferer generally experiences a kind of throb, or tumble 
in the region of the heart, or a choking sensation which may be attended 
with momentary faintness. A feeling of oppression at the chest, or ful- 
ness, or aching, is not uncommon. And sometimes the pain may be 
intense, prolonged, and indeed unbearable, extending over the whole car- 
diac region, or limited to some definite part of it, and often radiating 
thence to various parts of the trunk and to the extremities, especially down 
the arms. » 

3. Effects of Cardiac Derangements on the Walls and Cavities of 

the Heart. 

The effect of continued over-exertion of the heart, as of all other mus- 
cles, is hypertrophy. Its muscular tissue increases in quantity and its 
walls consequently in thickness ; and at the same time its cavities almost 
invariable undergo more or less dilatation. The hypertrophic walls are, 
as a rule, denser than those of the healthy heart, and often present, in 
addition to augmentation of muscular fibres, augmentation of connective 
and other tissues. Nevertheless it not unfrequently happens that, as dis- 
ease advances, the hypertrophied muscle becomes enfeebled in consequence 
of fatty or other degenerative changes. With this reservation, however, 
the degree of hypertrophy may be taken as a measure of the increased 
labor which the heart has been called upon to perform. Although proba- 
bly in some degree dilatation always accompanies hypertrophy, and owes 
its origin to the same cause, it must be regarded, not as an evidence of 
strength, but as the result of weakness — of the yieldingness of the heart's 
walls to the increased internal pressure to which they are subjected — and 
hence, although accompanying hypertrophy, as antagonistic to it. It will 
thus be readily understood that, other things being equal, a heart intrinsi- 
cally weak will become dilated more than hypertrophied under the stimulus 
of over-exertion ; that a heart intrinsically strong will, under similar cir- 
cumstances, become hypertrophied more than dilated. It must be added 
that dilatation, which is sometimes the primary organic change in hearts 
which are simply feeble, not only impairs efficiency, but actually furnishes 
an incentive to cardiac exertion and overgrowth. In the great majority 
of cases the dilatation of the cardiac cavities is uniform ; occasionally, 
however, the thinner parts of the walls, and especially softened or weak- 
ened areae, yield disproportionately. 

The above remarks are general. We will now apply them. When- 
ever any persistent obstacle exists to the passage of blood through the 
aortic orifice, along the arteries, or through the capillary network beyond, 
the left ventricle gradually gets hypertrophied, and in a greater or less 
degree dilated as well. For a time this hypertrophic change is almost 
purely compensatory ; the increased force of the cardiac contractions 
almost exactly counterbalances the effects of the obstacle ; the heart acts 
regularly, the ventricle empties itself completely at each systole, the mitral 



446 



DISEASES OF THE VASCULAR ORGANS. 



valve acts perfectly, and the auricle experiences no difficulty in the trans- 
mission of its contents into the ventricle. So far all the morbid changes 
are confined to the left ventricle ; but after a longer or shorter period dis- 
proportion arises between the hypertrophy of the ventricle, on the one 
hand, and its dilatation and the impediment to be overcome on the other; 
the ventricle fails to act efficiently, probably does not wholly expel its 
contents at each beat, and the auricle consequently begins to experience 
some difficulty in getting rid of its contents, and now in its turn becomes 
dilated and hypertrophic. The same sequence of phenomena follows that 
virtual impediment to the aortic circulation which results from aortic valve 
incompetence. In this case, however, dilatation doubtless precedes hyper- 
trophy, and the auricle probably becomes stimulated to over-exertion at a 
comparative early period. 

"Whenever disease, whether it be obstructive or regurgitant, exists at 
the mitral orifice, blood tends to accumulate in the left auricle, while 
increased force is needed for its propulsion thence ; the cavity, therefore, 
of the auricle becomes enlarged, and its walls thickened. But inasmuch 
as no valves exist at the orifices of the pulmonary veins, or in any part of 
the course of the pulmonary vessels, the augmented pressure of blood 
which commences within the auricle speedily spreads backwards through- 
out the entire pulmonary system. And hence arise impediments to the 
escape of blood from the right ventricle and its consequent hypertrophy 
and dilatation. 

Disease affecting the pulmonic orifice, equally with increased blood-pres- 
sure within the pulmonary artery, necessarily causes dilatation and hyper- 
trophy of the right ventricle, which are presently followed by similar 
affections of the right auricle. 

Disease of the tricuspid orifice provokes like changes in the right auricle 
and in connection therewith accumulation of blood in the systemic veins 
and dilatation of these vessels, to be gradually followed by similar condi- 
tions in the systemic capillaries and arteries and consequent obstruction to 
the escape of blood from the aortic orifice. 

It will be understood from the foregoing observations that when disease 
(actual or virtual) exists at any valvular orifice, first the cavity behind it 
becomes hypertrophied and dilated, and subsequently the same conditions 
gradually involve cavity after cavity in the backward direction until possi- 
bly every one becomes thus affected in a greater or less degree ; and, 
further, that in the extension of these conditions from the left auricle to 
the right ventricle, or from the right auricle to the left ventricle, the pul- 
monic or systemic vascular system, as the case may be, necessarily suffers 
from undue accumulation and pressure of blood within it. 

The form of the heart is greatly, and often characteristically, modified, 
by the hypertrophic and other changes above discussed. In general hyper- 
trophy and dilatation, such as are met with in chronic albuminuria, the 
shape of the heart is altogether unchanged. When aortic valve disease 
alone is present, the left ventricle is alone, or chiefly, enlarged ; and not 
only does its left edge extend further than usual to the left, so that more 
of the ventricle is exposed when we look at the organ in situ, but the apex 
projects far beyond that of the right ventricle. In mitral valve disease 
the left auricle becomes enlarged, but the right ventricle soon shares in 
the enlargement ; the left ventricle, on the other hand, is relatively small ; 
generally it either remains stationary or dwindles, or if it enlarges its 
enlargement is inconsiderable ; the heart consequently acquires a nearly 



EFFECTS OF CARDIAC DERANGEMENTS. 



447 



globular form, and the right apex either comes to share equally with the 
left in constituting the heart's apex, or forms it exclusively. The same 
shape of heart results from disease of the pulmonic orifice, or from chronic 
pulmonary disease ; but here the left auricle remains small. 

It must not be forgotten that a constantly palpitating heart becomes 
dilated and hypertrophied in consequence of its palpitation ; and that not 
only temporary violent muscular effort, but also habitual sustained exer- 
tion, induces similar organic changes. Dr. Allbutt, who has investigated 
this subject with close attention, believes that in such cases the hyper- 
trophy and dilatation commence on the right side of the heart, and are 
thence propagated to the opposite side. 

4. Effects of Cardiac Derangements on the General Organism. 

The disturbance to the circulation which results from cardiac affections 
cannot long continue without causing more or less serious disturbance of 
other organs or groups of organs. In connection with the pulmonary 
stasis which attends mitral disease and other equivalent conditions, we 
observe congestion and oedema of the lungs, effusion of blood into the pul- 
monary tissue (pulmonary apoplexy), thrombosis of the pulmonary arteries, 
which is generally associated with and is probably the cause of pulmonary 
apoplexy, tendency to inflammation, and all the symptoms — lividity, dysp- 
noea, and the like — which flow from such affections. In connection with 
systemic stasis there arise : general dilatation of veins and capillaries, with 
congestion and tendency to hemorrhage ; anasarca, especially of dependent 
parts; dropsy of serous cavities; and thrombosis. Moreover, the liver 
becomes congested and indurated, and assumes the well-known nutmeg 
character, and jaundice and other consequences of hepatic disorder ensue. 
The kidneys get similarly affected, and the urine grows scanty and albumi- 
nous ; and not unfrequently the gastro intestinal tract undergoes functional 
disturbance, or becomes the seat of hemorrhagic effusion or organic lesions. 
The central nervous system is especially apt to suffer ; from insufficient 
supply of blood to it arise attacks of syncope and epileptiform convulsions; 
from hyperemia, drowsiness and coma ; besides which headache, vertigo, 
and delirium are not uncommon ; and occasionally cerebral apoplexy from 
laceration of vessels ensues. There are several phenomena in connection 
with the systemic venous circulation, generally observed in. cases of disease 
of the right side of the heart, and not unfrequently in mitral disease, which 
call for special notice. These are : dilatation and pulsation of the larger 
veins ; pulsation of the liver ; and bulbous enlargement of the terminal 
phalanges of the fingers and toes. a. Dilatation and pulsation of the 
veins at the root of the neck, along the neck, and even down the arms,, is- 
not uncommonly observed. The dilatation is due to their over-repletion 
with blood ; the pulsation, as a rule, to the fact, that owing to this dilata- 
tion the venous valves allow of regurgitation, and that at the same time 
regurgitation takes place, during the contraction of the right ventricle,, 
through the tricuspid valve. The pulsation in marked cases may be not 
only seen but felt, and the sphygmographic tracing displays a double rise, 
of which the second is far more ample than the first, a circumstance which 
is due to the fact that the latter is caused by the auricular contraction, the 
former by that of the ventricle. It must not be forgotten, however, that 
pulsation of the veins at the root of the neck may be caused simply by 
auricular contraction when the veins are full, and that it may be simulated 



448 



DISEASES OF THE VASCULAR ORGANS. 



by the rhythmical distension of the veins which takes place during expi- 
ration, and by pulsation transmitted from neighboring arteries, b. It was 
first shown by Friedreich, and has since been confirmed by other observers, 1 
that, under similar circumstances to the above, hepatic pulsatijn not im- 
frequently occurs. It seems to be due to regurgitation into the vena cava 
ascendens, and thence into the hepatic veins. The pulsation ( which must 
be distinguished from ordinary epigastric pulsation, due to the direct 
influence of the action of the heart, or of the abnormal aorta) is visible 
over the whole extent of that portion of the abnormal surface with which 
the distended liver is in immediate relation, and may in many cases (espe- 
cially if the enlargement of the liver be considerable) be felt, in grasping 
the hepatic zone with the two hands, to be distinctly expansile. The 
sphygmographic tracing which may be obtained from the pulsating organ 
presents the same characters as those yielded by the venous pulse, and 
indicates a like origin, c. In cases of long-continued venous obstruction 
(and especially, therefore, in heart disease of congenital origin), the last 
phalanges of the toes and fingers become more or less livid and swollen or 
bulbous — a condition which is also observed in phthisis and several other 
affections. Finally, we must not forget to allude to the consequence of 
the detachment of cardiac vegetations, or particles of atheromatous or 
calcareous detritus, or of the escape of the contents of softened clots — 
namely, embolic obstructions of the arteries of various organs, but more 
especially of those of the brain, spleen, kidneys, liver, and lungs. 

5. General Diagnosis of Cardiac Derangements. 

So far as physical diagnosis is concerned, the most important points to 
which we have to attend in the investigation of cardiac diseases, are : 
first, alterations in the form of the precordial region ; second, alterations 
in the area over which dulness on percussion extends ; third, changes of 
resistance ; fourth, the situation, extent, and character of the cardiac pul- 
sation, together with the presence or absence of vibration or tremor ; and, 
fifth, the presence of abnormal sounds. 

a. Alterations in the form of the precordial region can generally be 
easily recognized by mere inspection. Frequently, when the heart is en- 
larged, and still more when there is effusion into the pericardium, this 
region becomes distinctly prominent over a greater or less extent of sur- 
face. This change is much more readily produced in the child than in the 
adult. When much pericardial effusion is present the intercostal depres- 
sions of the implicated region are apt to be smoothed away and effaced ; 
sometimes, indeed, they bulge. The degree and extent of protrusion may 
be determined : partly by comparing by actual measurement, or by the 
cyrtometer, the horizontal circumference of the two halves of the chest ; 
partly by comparing, on the two sides, the relative distances between any 
corresponding pairs of points, as for example, those between the nipples and 
the mid-line of the sternum, the width of corresponding intercostal spaces, 
and the like. 

b. Alterations in the area of cardiac dulness must be ascertained either 
by the use of the pleximeter and hammer, or by the ordinary mode of 
percussion. Dulness over the precordial region, like other forms of dul- 
ness, varies in quality in different individuals (according to the quantity of 



» Dr. Frederick Taylor, 'Guy's Hospital Reports,' 1875. 



DIAGNOSIS OF CARDIAC DERANGEMENTS. 



449 



fat or flesh in the thoracic parietes, and the condition of the bony frame- 
work) from the almost imperceptible sound produced by percussing the 
thigh, or the sharpish click which may be elicited from the patella or the 
forehead, to the comparatively dull thud which is yielded by the sternum. 
Even in the same individual, the dulness elicited over the sternum is 
markedly different from that obtained over the costal cartilages ; and 
indeed the presence of dulness must be determined less by the absolute 
sound which is elicited than by comparing it with the sounds yielded by 
percussion of neighboring parts, and more especially of corresponding parts 
on the opposite side of the chest. Increased area of dulness may depend 
either on pericardial effusion, on hypertrophy or dilatation of the heart, on 
the presence of tumors, or on the retraction of the free edges of the lungs. 
On the other hand, extension of dulness in cardiac disease may be coun- 
teracted or annulled by the presence of pulmonary emphysema. 

c. Increased resistance is, for the most part, due to the presence of 
thick, dense, pericardial adhesions, or of solid growths of other kinds. It 
may occasionally be detected by mere pressure of the hand, but is most 
strikingly revealed by the entire absence of that yieldingness which is 
generally so obvious on percussion of the thoracic parietes. 

d. Pulsation and thrill — The apex of the heart changes its position 
under various circumstances. In hypertrophy, it is found beating below 
and external to its normal site. In pericarditis with effusion the apex is 
somewhat elevated, and this elevation is said to be maintained to some 
extent even after adhesion has taken place. Sometimes the cardiac pul- 
sation extends over a large surface. This is especially observable in cases 
of hypertrophy ; and in hypertrophy of the right ventricle pulsation be- 
comes strikingly obvious in the epigastrium. Extension of pulsation is 
also manifested in cases of pericardial effusion ; but the pulsation is then 
due mainly to the undulations which the heart excites in the surrounding 
fluid, and is not strictly synchronous with the cardiac movements. Again, 
the cardiac pulsation varies in character. In hypertrophy it is prolonged 
and heaving, in palpitation it is short and violent, and in some cases of 
associated hypertrophy and dilatation, a distinct impulse or jog attends the 
diastole as well as the systole. In the last case, too, it often happens that 
the systolic impulse of the apex is accompanied by an obvious subsidence 
of the rest of the precordial region. But, besides these, certain adventi- 
tious movements of the thoracic parietes are sometimes present in cardiac 
diseases, such as tremor or fremitus — trembling or vibratile movements, 
which are occasionally likened to the purring of a cat. They are some- 
times present in pericarditis, but still more obviously in certain forms of 
valve disease, more especially regurgitant aortic and direct mitral. 

e. The production of abnormal sounds by the movements of the heart, 
or of the blood which passes through it, may be recognized either by the 
ear applied to the cardiac region, or by means of the stethoscope. These 
sounds are usually termed 'murmurs,' or 'bruits.' 

i. Pericardial murmur, or friction sound, is produced by the attrition 
of the roughened surfaces of the heart and parietal pericardium. It varies 
in character : being sometimes a uniform to-and-fro sound, like that pro- 
duced by rubbing two pieces of paper together; sometimes a more or less 
uniform crackling, rumbling, or creaking; sometimes a series of irregular 
jogs, which are generally more numerous than the sounds of the heart, and 
rarely synchronous with them, and depend on the fact that the equable 
movement of the opposed surfaces on one another is interfered with by the 
29 



450 



DISEASES OF THE VASCULAR ORGANS. 



obstacle which their roughness or stickiness interposes. Pericardial sounds, 
especially if of limited extent, are not always distinguishable from endo- 
cardial murmurs; they rarely, however, present much intensity, are prob- 
ably never musical, and are scarcely perceptible except immediately over 
the part at which they are developed, ii. Endocardial murmurs may arise 
at any one of the four valvular orifices of the heart, during either the sys- 
tole of the ventricles or their diastole. Thus, at the aortic or the pulmonic 
orifice murmurs may be developed, either while the blood is flowing from 
the ventricle into the artery ; or during the period of diastole, in conse- 
quence of the reflux of blood from the artery into the ventricle. The 
former murmurs are known as systolic or direct, the latter as diastolic or 
regurgitant, of the respective arterial orifices. And so also, at the mitral 
or the tricuspid orifice, a murmur may arise, either during the systole of 
the ventricle in consequence of regurgitation of blood from the ventricle 
into the auricle, or during the diastole of the ventricle while the blood is 
pursuing its normal course from the auricle into it. The former murmurs 
are respectively systolic mitral and systolic tricuspid, and are at the same 
time regurgitant; the latter are diastolic or direct. Cardiac murmurs 
either replace the normal sounds of the heart or are superadded to them. 
They are necessarily loudest at the points at which they are developed ; 
but in consequence of the intervention of cardiac structures which are not 
implicated, or of the free edges of the lungs, they are not necessarily loud- 
est at those portions of the chest surface which are nearest to these points. 
Again, they are carried, as might be supposed, by the blood-stream, and 
are hence louder in the course of that stream than in the opposite direction. 
Endocardial murmurs present a wide range of character, dependent on 
differences of intensity, quality, and pitch. As to intensity, they may be 
so soft as to be barely detectable, or so loud as to be distinctly audible by 
the unaided ear at a short distance from the pericardial region. As to 
quality, they may resemble a simple whiff, a whispered vowel, a whispered 
r, or a prolonged s; they may be harsh and rough, or grating, or they 
may have a more or less distinctly musical character. And lastly, the 
musical note may vary in pitch from bass to treble, from a deep hum or 
buzz to a whistle. They are often compared to sounds with which we are 
familiar, such as blowing, cooing, sawing, rasping, and the like ; and, 
apart from such special qualities, are usually distinguishable from the nor- 
mal heart-sounds by their greater prolongation, and by the fact of their 
comparatively gradual subsidence. Endocardial murmurs are the result 
of molecular vibrations produced in the blood as it traverses one or other 
of the cardiac orifices. Molecular vibrations are of course always present, 
whether in health or disease, but they are only rendered sufficiently in- 
tense to evolve sound either when the blood is driven with unnatural 
velocity through one of the orifices (as sometimes happens at the healthy 
aortic or pulmonic orifice in anaemia or palpitation), or when it meets in 
its course with some impediment, or encounters some roughness or pro- 
jection, or some pendulous vibratile body, or when, as in regurgitation, 
opposing streams meet and cause eddies. It is not always possible, nor is 
it important, to determine the conditions on which the different qualities 
of murmurs depend. It may, however, be remarked that roughness or 
hoarseness of sound implies for the most part roughness or irregularity 
(however produced) at the orifice at which it is developed, and that musi- 
cal quality may be determined by extreme narrowness of orifice, and 
especially by such conditions of the edges of an orifice as permit them to 



DIAGNOSIS OP CARDIAC DERANGEMENTS. 



451 



perform regular vibrations. The roughest and most grating murmurs 
probably are the consequence of partial detachment of valves, or of rup- 
ture of chordae tendinese, which allows the implicated valve to flutter loosely 
in the blood-current. The most distinctly musical sounds are chiefly ob- 
served in murmurs due to regurgitation, as might be supposed from the 
combination of narrowness of orifice and of vibratile edges which is then 
commonly present. There can be no doubt that the quality of cardiac 
murmurs is often very distinctly modified by the resonance of the blood- 
containing ventricular cavities ; in fact, that murmurs not otherwise musi- 
cal are thus rendered more or less musical, and that musical murmurs 
have some of their harmonics developed by this means with dispropor- 
tionate power. It is obvious that such modifications must occur mainly 
while the ventricles are filling or full, and hence specially affect murmurs 
developed during the ventricular diastole. It is probable that the deep 
tone of so-called ' presystolic' murmurs is in some measure due to this 
circumstance ; and that the different qualities of the same murmur, as 
heard over the aortic orifice where it is created, and at the apex whither 
it is conveyed, are similarly explicable. 

Reduplication of the sounds of the heart, though occasionally observed 
in health, is, for the most part, an indication of disease. It may be heard 
under various conditions ; but reduplication of the first sound is chiefly 
met with in connection with hypertrophy of the heart and high arterial 
tension, especially, therefore, in chronic Bright's disease ; and reduplica- 
tion of the secoiid sound is not unfrequently observed in affections of the 
mitral valve. 

f. Venous murmurs — It may be added here that venous murmurs, con- 
sisting of a continuous humming or buzzing, whistling or hissing, are not 
uncommon in the larger veins wdien they are partially obstructed, and es- 
pecially in anaemic patients. They may generally be best detected in the 
neck, particularly on the right side. 

6. Special Diagnosis of Cardiac Derangements. 

a. Pericardial effusion is indicated locally : by bulging of the precor- 
dial region, with more or less distinct effacement of the corresponding 
intercostal spaces ; by diffused undulatory pulsation and elevation of the 
cardiac apex ; by extension of dulness, which assumes a triangular form, 
and, taking place mainly upwards, may reach from the clavicle above to 
the diaphragm below, and be bounded to the left by an oblique line pass- 
ing from the junction of the left first rib and cartilage downwards and 
outwards through or beyond the left nipple, and on the right by a line 
running, for the most part, vertically somewhere between the right nipple 
and the median line of the sternum. The effect of pericardial effusion 
on the heart is to embarrass its action, to cause it to beat quickly, weakly, 
and irregularly, and to deaden its sounds. The pulse becomes correspond- 
ingly affected. The patient suffers from shortness of breath, pain or diffi- 
culty in breathing or palpitation, and not unfrequently, owing to interfer- 
ence with neighboring organs, complains of fulness in the throat and diffi- 
culty of swallowing. 

b. Pericardial adhesion, which is commonly the consequence of pericar- 
ditis, cannot always be recognized by either local or general signs. If it 
occur simply in patches, or if, being general, it be caused by a delicate 
adventitious lamina, there will probably be nothing whatever to indicate 



452 



DISEASES OF THE VASCULAR ORGANS. 



its presence. If, however, the accumulation of fibroid material be thick 
or dense, there will necessarily remain more or less permanent increase of 
the area of cardiac dulness, more or less disturbance of the heart's action, 
and more or less tendency to the development of the ordinary symptoms of 
chronic heart disease. The local indications of adherent pericardium are 
mainly permanent extension of precordial dulness, elevation of the apex 
of the heart, and displacement to the left, and, it is said, recession of the 
thoracic walls over the apex of the heart at the time of systole in place of 
the normal protrusion. 

c. Hypertrophy of the heart (as has been already shown) is probably 
always associated with more or less dilatation, always originates in over- 
work, and is in a very large proportion of cases developed, in obedience 
to its exciting cause, more largely on one side of the heart than the other. 
From these statements, it will be seen that the presence of hypertrophy 
and its distribution may generally be predicted from a knowledge of the 
existence of one of the recognized causes of hypertrophy ; and, further, 
it may be gathered that cardiac hypertrophy seldom, if ever, exists in an 
uncomplicated form. The presence of hypertrophy is generally indicated 
by extension of precordial dulness, prominence of the precordial region, 
and powerful, heaving, diffused, cardiac impulse. If the hypertrophy be 
general, or involve mainly the left side, the apex of the heart gets dis- 
placed downwards and outwards, and may be found as low as the seventh 
interspace or eighth rib, and an inch or two outside the nipple ; moreover, 
the pulse becomes hard and sustained, and the arteries get tense, and 
manifest a tendency to degenerate and yield. If hypertrophy affect the 
right side only or in chief part, epigastric pulsation becomes a prominent 
feature, and the apex beat is diffused and ill-defined. In this case the 
pulsation of the systemic arteries is not necessarily affected, the tension is 
limited to the pulmonary vessels, and it is these which are, after a time, 
apt to become dilated and to degenerate. The cardiac sounds, and more 
especially the first, are said to be duller than natural in simple hypertrophy 
but to become much increased in loudness when dilatation is associated 
with hypertrophy. 

d. Feebleness of the heart is a consequence of numerous different kinds 
of lesions, such as dilatation, and degenerative changes of its walls ; and 
is a late result of most organic affections of the organ. It is attended with 
more or less feebleness of the cardiac sounds and beats, and a corresponding 
condition of the pulse, which is sometimes increased in frequency, some- 
times slower than normal, and often irregular. The patient moreover has 
difficulty of breathing, and palpitation, especially under excitement or on 
exertion ; probably cardiac neuralgia ; liability to faint ; and venous con- 
gestion with tendency to rapid supervention of dropsy and the other usual 
consequences of heart disease. The symptoms are scarcely distinguishable 
from those of incompetence of the mitral valve, with which lesion, indeed, 
debility of the heart is often associated. Enfeeblement of the heart is one 
of the recognized causes of sudden death. 

e. Aortic valve disease Obstructive disease or stenosis is characterized 

by the presence of a murmur which commences with the commencement 
of the heart's systole, and is continued onwards during the systolic silence. 
It is usually loudest over the right half of the sternum at the level of the 
third cartilage or third interspace, is very distinct over the ascending arch, 
and sometimes even in the back along the descending arch and upper part 
of the thoracic aorta ; and it diminishes in force as it is traced from the 



DIAGNOSIS OF CARDIAC DERANGEMENTS. 



453 



base of the heart to the apex. The extent of its diffusion depends largely 
upon its loudness or pitch ; when feeble it may be audible only over the 
valve and ascending arch. It is synchronous with the carotid pulse and 
cardiac impulse. The diagnosis of aortic valve disease is aided by the 
hypertrophic condition of the heart which attends it, and by the prolonged 
elevation of the systolic element of the pulse. In aortic regurgitation, 
the murmur which is produced commences with the second sound of the 
heart, which in some cases it entirely replaces, and is generally much pro- 
longed, sometimes up to the very commencement of systole. It is usually 
most distinctly audible in the neighborhood of the aortic orifice, and is 
carried thence downwards by the refluent stream towards the apex, often 
more particularly along the sternum, diminishing, however, in intensity in 
its passage, and sometimes undergoing some change of quality. Occa- 
sionally it is most distinct over the lower part of the sternum. It is in 
general rapidly lost along the ascending arch. If feeble, it may be detect- 
able only over the valve and the adjoining portion of the ventricle. It 
occurs alternately with the carotid pulsations and the cardiac impulses. 
Its diagnosis is assisted by the fact of the heart being dilated and hyper- 
trophied and by the character of the pulse. The latter has usually a pecu- 
liar jerky quality, which is due to a combination of sudden violence of 
the systolic wave w T ith an equally sudden collapse at the beginning of the 
diastolic period — the latter being so sudden and extreme that the clicrotous 
rise is almost or entirely suppressed. This variety of pulse is usually 
termed Corrigan's, or the 1 water-hammer' pulse. 

f. Pulmonic valve disease A systolic murmur produced at the pul- 
monic orifice is heard loudest over the left edge of the sternum, or about 
the level of the third costal cartilage. It is heard also over the trunk of 
the pulmonary artery, namely, at or about the left edge of the sternum, as 
high as the upper border of the second cartilage. But it is inaudible, or 
nearly so, to the right of the sternum and along the ascending aortic arch, 
and fades away as it is traced downwards over the right ventricle. Organic 
murmurs at this orifice are rare, excepting as the result of congenital dis- 
ease. The most common by far are anaemic. Regurgitant murmurs from 
defect of the pulmonic valve are of extreme rarity. They would naturally 
be best heard over the diseased valve, and thence downwards towards the 
right apex. 

g. Mitral valve disease — Of all murmurs the systolic mitral, or that 
due to regurgitation through the mitral orifice, is the most common. It 
attends the systole of the heart, and, therefore, like the direct aortic is 
synchronous with the carotid pulse. It is usually heard most distinctly, 
not immediately over the valve, but over that part of the left ventricle 
which is most superficially placed, namely, the apex. If feeble it may be 
audible in this position only, but, if loud it is often heard over the w r hole 
of the precordial region. In the latter case it generally diminishes in 
force from the apex to the base ; but occasionally increases again over the 
aortic orifice, or at that part of the left ventricle which, next to the apex, 
approaches nearest to the surface of the thorax. A systolic regurgitant 
murmur is carried back with the refluent blood into the left auricle ; and 
partly on this account, partly because of the situation of the left ventricle 
to the left and back of the heart, it is generally distinctly audible about the 
angle of the left scapula, and along the horizontal line passing from this 
point to the apex of the heart — a fact of great importance in the recogni- 
tion of this murmur. Direct mitral murmurs occur during the diastolic 



454 



DISEASES OP THE VASCULAR ORGANS. 



period, and until of late years were generally overlooked or misinterpreted. 
They are often absent because, although obstructive disease is not uncom- 
mon, the force with which the blood passes from the auricle into the ven- 
tricle is generally insufficient to generate a murmur. It is well known, 
however, to physiologists that during the earlier period of the ventricular 
diastole the blood is flowing almost passively through the auricle into the 
ventricle, and that it is only at the last, just before the ventricle itself con- 
tracts, that the auricle contracts and propels its blood with vigor. It is at 
this moment, therefore, that a murmur is most likely to be developed. It 
need scarcely be added that, when the auricle has become, as it soon does, 
dilated and hypertrophied, and the time occupied in discharging its con- 
tents more or less protracted, the murmur is likely to be rendered both 
more intense and of longer duration. A diastolic mitral murmur, then, is 
audible during the ventricular diastole, but generally nearer its end than 
its beginning, sometimes indeed running up to the systolic sound, and ap- 
parently blending with it. More commonly the rhythm of the heart appears 
to be altered at the apex, The interval between the murmur and the first 
sound is so short that there is frequently a tendency, on listening at the 
apex, to reckon the murmur as the first sound, the true first sound as the 
second, and, from its indistinctness in the neighborhood of the apex, either 
to disregard the true second sound, or to look upon it as a mere reduplica- 
tion ; or, if there be a systolic murmur, to take the second sound for an 
accentuated portion of it. From the usually peculiar relation of the dia- 
stolic mitral murmur to the ventricular systole, it is often termed ''pre- 
systolic.' From the fact of its being determined by the auricular systole 
Dr. Gairdner names it auricular systolic. There seems no good reason, 
however, why the name diastolic mitral should not be retained for it. This 
murmur is generally of short duration, somewhat deep-toned and rough, 
and to be heard over a very limited area at the apex of the heart, or a 
little to its inner side. It is very seldom audible in the back or at the 
base. It is important to note that a prns-systolie murmur is often attended 
with a sensible thrill or purring sensation, that it is apt to be very irregu- 
lar or unequal in its production, and that, above all murmurs, it is liable 
to disappear when the circulation is tranquil, and to become distinct when 
the heart's action is excited. In order to identify the prre-systolic mur- 
mur, it is essential either that the pulse should be felt while the heart is 
being auscultated, or that the sounds at the base and apex should be simul- 
taneously examined by means of a double stethoscope. 

In both mitral regurgitation and mitral obstruction, the ventricle tends 
to propel a comparatively small quantity of blood into the aorta at each 
systole, and consequently the pulse tends to be small and feeble, the arte- 
rial tension to be diminished, and more or less distinct dicrotism be mani- 
fested. Further, the action of the heart, and consequently the pulse, soon 
become irregular. 

h. Tricuspid valve disease Disease of the tricuspid valve is rare ; it 

is also rare to have a murmur produced at this orifice. A direct murmur 
or one attending the ventricular diastole, is of exceedingly infrequent oc- 
currence. A regurgitant or systolic murmur is much more common ; but 
this is more frequently due to over-distension of the ventricle or compara- 
tive shortness of the musculi papillares, and consequent inadequacy of the 
valves, than to their structural disease. It is sometimes observed in the 
displaced hearts of persons suffering from angular curvature of the dorsal 
vertebrae in whom also the right ventricle is sometimes much hypertro- 



PROGNOSIS OF CARDIAC DERANGEMENTS. 



455 



phied. The murmur is generally somewhat low-toned, audible most dis- 
tinctly about the ensiform cartilage, diminishing thence towards both the 
left apex and the base, and absent at the back of the chest. Tricuspid 
obstruction and regurgitation are attended with more or less obvious ful- 
ness of the systemic veins, especially those of the neck and upper arm ; 
and not unfrequently distinct pulsation, apparently synchronous with that 
of the ventricle, may be distinguished in them and in the liver. 

i. Hcemic murmurs. — But besides those due to valvular incompetence 
or impediment, other murmurs of functional origin are not infrequently ob- 
served. They are for the most part temporary, and are especially apt to 
occur when the heart is acting with unwonted violence, and in persons — 
more particularly young women — who are markedly anaemic. They are 
always systolic, and generally chiefly audible at the base of the heart, 
either to the right or to the left of the sternum. Occasionally they are 
observed at the apex. When heard at the base they probably arise in the 
commencement of the aorta or pulmonary artery. It is maintained, how- 
ever, by Naunyn, and his views are adopted by Dr. Balfour, that these 
murmurs are really mitral and regurgitant, and that they are heard in fact 
over the left auricular appendage, into which they are carried by the re- 
fluent blood-stream. If this were true, however, we ought to hear ordi- 
nary regurgitant mitral murmurs best in the same situation. When the 
murmurs are at the apex they are certainly regurgitant, and due probably 
to temporary dilatation of the ventricle, and consequent incompetence of 
the mitral valve. 

7. Prognosis of Cardiac Derangements. 

a. Our prognosis of pericardial effusion must depend largely upon what 
we know of its cause ; and its causes we need scarcely say are numerous. 
We may point out, however, that when effusion takes place rapidly, as it 
does when an aneurism or the heart itself ruptures into the pericardium 
the effects are remarkable : the cavity becomes rapidly distended, and the 
heart presently ceases to act, mainly, if not entirely from its inability to 
contend against the compressing force to which it is subjected. When, 
however, effusion takes place slowly, the parietal pericardium undergoes 
gradual distension, and enormous accumulation may then ensue with only 
moderate embarrassment of the heart's action. 

The consequences of adhesion of the pericardium are various ; in many 
cases no influence whatever is exerted upon the muscular parietes or the 
action of the heart, and the patient continues in good health ; in many 
cases, however, especially if the adhesions be abundant or thick, the action 
of the heart become more or less seriously embarrassed, and this embar- 
rassment involves in some cases hypertrophy and dilatation, in some 
atrophy of the organ, and in either case aggravation of the patient's symp- 
toms. 

h. Hypertrophy is in most cases compensatory, and therefore rather a 
benefit than an injury to the patient; dangers, however, follow in its train, 
the more important of which are dilatation of cavities, incompetence of 
valves, and degenerative changes in the muscular tissue of the heart itself 
and in the arterial system — all of them indications and sources of failing 
strength. 

c. Whenever a diseased heart becomes also enfeebled, the symptoms 
from which the patient suffers are greatly aggravated. Weakness of the 



456 



DISEASES OF THE VASCULAR ORGANS. 



heart, indeed, whenever it occurs apart from and out of proportion to weak- 
ness of the general system, is always of grave import. 

d. In attempting to estimate the relative prospects of life of patients 
suffering from the various forms of valvular lesions, many different mat- 
ters have to be taken into consideration. Thus, if the affection be due to 
rheumatic inflammation, we know that the patient has special liability to 
a recurrence of his rheumatism, and consequently to aggravation of his 
cardiac malady ; if the disease be the consequence of senile changes, we 
know that the valve affection must, in the nature of things, be progressive ; 
and both in these and in other cases there is often something in the condi- 
tion of the valves, only to be guessed at during life, which renders the 
danger of embolism always imminent. Again, the constant bodily or 
mental labor to which many sufferers are condemned necessarily influences 
symptoms unfavorably and hastens death ; further, any conditions of fail- 
ing health which tend to enfeeble the muscular walls of the heart tend, on 
this very account, to affect injuriously in a disproportionate degree the due 
action of the organ, and to expedite the fatal issue ; and lastly, inflamma- 
tory and other affections of the lungs, which embarrass the pulmonary 
circulation, form especially serious and dangerous aggravations. of all forms 
of heart disease. 

But, putting aside all these sources of danger, which are more or less 
accidental, and common to most varieties of heart disease, the question 
remains, ' what, cceteris paribus, are the relative prospects of life of those 
suffering from the different valvular lesions ?' and (it may be added) ' what 
are the special dangers to which they are respectively liable ?' Obstruc- 
tive disease at a valvular orifice is a much less serious matter than regur- 
gitant disease, inasmuch as the hypertrophy of the muscular walls of the 
cavity behind becomes for the most part accurately adjusted to the in- 
creased work which is thrown upon them. The adjustment is often so 
accurate in the case of aortic valve obstruction, that persons thus affected 
occasionally live for years unconscious of the presence of disease. Indeed, 
this is certainly the least serious of all valvular lesions. Obstructive mitral 
valve disease, again, unless it be extreme, is pretty successfully counter- 
acted by hypertrophy of the left auricle. Compensative hypertrophy o£ 
the auricle, however, can scarcely be so efficacious as that of the ventricle, 
since the absence of valves at the entrance of the veins allows the in- 
creased blood-pressure to be easily propagated backwards through the pul- 
monary vessels. It is certain, indeed, that in a large proportion of these 
cases symptoms of cardiac disease manifest themselves before long ; but, 
on the other hand, it is also certain that many persons who labor under 
congenital constriction of the mitral orifice live for many years, and for a 
large portion of their lives suffer little. No degree of hypertrophy can 
neutralize the effects of regurgitation. Indeed, it is questionable whether 
the hypertrophy which always follows on regurgitation is in any degree 
compensative of that regurgitation ; whether, indeed, it is not to be 
regarded as the result of an effort to neutralize the virtual weakness which 
the dilatation, always attending regurgitation, causes. Aortic regurgitant 
disease is probably the most serious and rapidly fatal of all forms of valvu- 
lar lesion. Regurgitant disease of the mitral is certainly less serious than 
the last, and patients often labor under it for many years ; nevertheless it 
is probably more dangerous than obstructive disease of the same orifice. 
The order of danger in which Dr. Peacock places the four lesions which 
have just been considered, and we concur with him in this matter, is as 



TREATMENT OF CARDIAC DERANGEMENTS. 



457 



follows : first, aortic regurgitant ; second, mitral regurgitant ; third, mitral 
obstructive ; and fourth, aortic obstructive. It need scarcely be remarked, 
however, that this order is necessarily often departed from ; that regurgi- 
tation (although productive of a murmur) may be so slight as to be of 
comparatively little moment ; that obstruction may be so extreme as to 
lead to the rapid destruction of life. Diseases of the right side are so rare 
and when present so often associated with lesions of the left side, that it is 
impossible, excepting theoretically, to estimate their relative degrees of 
danger. 

We have previously discussed the various consequences of heart disease ; 
and from what was then said the causes of death in patients suffering from 
valvular lesions may for the most part be determined. Sudden death, 
which was formerly so largely attributed to heart disease, is not a common 
sequela of valvular lesion. It is most common in regurgitant aortic dis- 
ease, and in that case is due to syncope, or perhaps, as some maintain, to 
cardiac ansemia from non-filling of the coronary arteries. 

8. Treatment of Cardiac Derangements. 

a. The treatment of pericardial effusion will be best considered with the 
various morbid conditions on which it depends ; that of embarrassment of 
the heart from adherent pericardium resolves itself mainly into that of 
enfeeblement of the cardiac walls, which will be referred to further on. 

b. The treatment of simple cardiac hypertrophy is a matter of simpli- 
city. We can only remove hypertrophy by removing or obviating the 
lesion which has provoked it, by maintaining the circulation in an equable 
and quiet condition by the avoidance of mental and bodily excitement or 
over-exertion, and by careful attention to the healthy maintenance of the 
funations of the body generally. It is, however, of the highest import- 
ance to delay or prevent the supervention of that enfeebled condition of 
heart in which hypertrophy so commonly and disastrously ends ; and this 
must be effected by promoting the general health of the patient ; for which 
purpose iron and other tonics, change of air, and nourishing diet are often 
necessary. 

c. The treatment of cardiac debility differs little, if at all, from that 
needed in the later stages of valvular, and more especially mitral valvular 
disease, a subject presently to be considered. 

d. In treating valvular disease we must never forget that we are dealing 
with affections which, in the nature of things, are incurable; that valvu- 
lar defects tend, on the whole, to increase ; that their ill effects tend grad- 
ually to become augmented by the changes which take place secondarily 
to them in the walls and dimensions of the cardiac chambers, and are 
always liable to serious aggravation by the presence of any condition, be it 
normal or morbid, which embarrasses the circulation. Our primary object 
must, therefore, be to prevent, or at all events to delay, the supervention 
of those numerous morbid processes and symptoms which have already 
been adverted to as the consequences of heart disease. We cannot repair 
the injured valve. We cannot, and would not if we could, prevent the 
compensatory hypertrophy which ensues ; we may, however, by forbidding 
excessive muscular exertion, or taking precautions against mental excite- 
ment, or other provocatives of increased cardiac action, prevent in many 
cases that hypertrophy from becoming excessive, and therefore injurious. 
We cannot prevent a certain amount of dilatation from taking place in 



458 



DISEASES OF THE VASCULAR ORGANS. 



association with hypertrophy ; but by the same measures by which we 
counteract the one we tend also to counteract the other ; and, further, 
since dilatation is to a large extent dependent on impairment of muscular 
strength, we may, by maintaining the general strength, maintain also to 
some extent that of the heart itself. Lastly, we may often succeed by 
careful attention in preventing the recurrence of inflammatory attacks, in 
arresting pulmonary and other congestions which react deleteriously on 
the heart, and in maintaining the quality and quantity of the blood in a 
fairly normal condition. 

Hence a patient whose heart is diseased should abstain from all forms 
of violent and sustained exertion, and should never push even what seems 
to be moderate exercise to the extent of causing shortness of breath, or 
palpitation, or uneasy feelings of any kind, or even fatigue. His pursuits 
and surroundings should be such as do not entail mental excitement. He 
should be protected by proper clothing and other precautionary measures 
against cold. His bodily health should be maintained by the use of whole- 
some, nutritious, but not too abundant food, by the cautious employment 
of stimulants, and by carefully regulating the action of his emunctories. 

But, notwithstanding the greatest care, a time comes sooner or later, 
and comes soon to those who are compelled to work hard for their liveli- 
hood, when the consequences of the cardiac lesion becomes painfully appa- 
rent. The patient begins to suffer from palpitation, irregularity of pulse, 
shortness of breath, dropsy, jaundice, albuminuria, pulmonary apoplexy, 
angina. But even in these cases it is remarkable how often, under the 
influence of perfect rest and the other items of treatment which have been 
enumerated, all unfavorable symptoms subside. Indeed, in the treatment 
of the symptoms and consequences of valvular disease there is no doubt 
that absolute rest is of far more value as a remedial agent than anything 
else that can be named. But in aid of rest other agents may often be 
beneficially employed. Frequency of pulsation, and especially irregularity, 
are almost invariably connected with feebleness and. irritability of the 
heart's action. To remedy this condition it seems desirable first to give 
strength to the heart's contractions, and next to diminish their frequency. 
For the former of these purposes iron and the vegetable tonics, and possi- 
bly nux vomica, are valuable ; for the latter probably no drug, at any rate 
in mitral valve disease, is superior to digitalis. A combination of digitalis 
with iron is often of very great value. Belladonna is by many preferred 
to digitalis in the treatment of lesions of the aortic valve. To relieve 
the overloaded venous system, to which so many of the resultant phe- 
nomena of valvular disease are due, we may employ diaphoretics, diuretics, 
and purgatives, and besides these in some cases the removal of blood by 
leeches or cupping, or by venesection. Further, to relieve shortness of 
breath or engorgement of the lungs, or prascordial uneasiness, ether, am- 
monia, lobelia, stramonium, squills, ipecacuanha, or other expectorants, 
opium and counter-irritants may all of them, under slight modifications of 
circumstances, be of use. 



PERICARDITIS. 



459 



II. PERICARDITIS, MYOCARDITIS, AND ENDOCARDITIS. 

A. Pericarditis. 

Causation Inflammation of the pericardium is evoked in various ways: 

by extension from the muscular walls of the heart when these contain 
abscesses ; by extension from the pleura, peritoneum, cellular tissue of the 
neck, posterior or anterior mediastinum, or any other neighboring part 
which is the seat of inflammation ; by local injuries, such as penetrating 
wounds of the pericardium, or the opening of sinuses from hepatic or other 
abscesses into it ; and by the rupture of aneurisms, hydatid cysts, and 
the like. The most frequent and important cause of pericarditis, how- 
ever, is exposure to cold, especially if that exposure results in the develop- 
ment of rheumatic fever. Pericardial inflammation not unfrequently 
occurs in association with, if not in dependence upon, chronic albuminuria, 
scarlatina, chorea, pyaemia, and occasionally in connection with tubercular, 
syphilitic and carcinomatous or other malignant growths. 

Morbid anatomy Inflammation of the pericardium, like that of all 

other serous membranes, is characterized in the first instance: by dilatation 
of the bloodvessels and consequent hyperemia; effusion of their fluid con- 
tents into the substance of the serous membrane, and into the subserous 
tissue ; and tendency to proliferation of the endothelium. At first, little 
more than simple congestion and oedematous thickening of the membrane 
is present. But soon inflammatory exudation takes place, consisting 
partly of fibrine, which as it is secreted coagulates upon the surface, and 
remains adherent to it or blended with it ; partly of serum, which, containing 
dissolved albumen and fibrinogen, accumulates in the pericardial cavity, 
and separates one surface of the membrane from the other ; and partly of 
inflammatory corpuscles, derived either from the proliferating endothelium 
or from errant leucocytes of which the majority remain entangled in the 
coagulating fibrine. 

The relative quantities of solid and fluid exudation, their characters 
and the changes which they undergo, present great varieties. In some 
cases of pericarditis, which is thence often termed ' dry,' the whole sur- 
face becomes covered with a greater or less abundance of false membrane, 
but there is little or no accompanying serous effusion. In most cases, 
however, a few ounces of fluid are poured out in the course of the affection. 
And occasionally the accumulation amounts to one, two, or even three 
pints. 

The solid exudation or false membrane forms in the early stage of its 
production a thin, slightly coherent lamina, which is scarcely distinguish- 
able except from the fact that it robs the serous surface of its normal 
smooth glistening aspect. But it soon increases in quantity by the addition 
of fresh inflammatory matter to its free surface, and may thus by degrees 
attain the thickness of paper, cardboard, or of ^ or even ^ inch. As its 
thickness increases, so also as a rule do the density and closeness of ad- 
hesion of its deep surface, and the irregularity of its free aspect. At first 
the latter is merely faintly granular, but it soon gets more or less villous 
or tuberculated, or pitted with irregular and deepish holes. It is difficult 
to give in a few words a notion of the different appearances which may be 
presented: in some cases the surface is honeycombed; in others it is ribbed 
like the sand which the waves have just left ; in others it has the aspect 



460 



DISEASES OF THE VASCULAR ORGANS. 



which may be produced by separating two hard smooth surfaces which 
have been stuck together with a layer of butter; in others again the exu- 
dation has been clearly rolled by the to-and-fro movements of the heart 
into cylindriform pellets, which remain irregularly attached to one or both 
surfaces of the pericardium. And further, irregular bands, festoons, or 
lamina? of the same material not unfrequently extend in greater or less 
abundance between the visceral and parietal layers. 

The pericardial fluid is sometimes limpid and colorless, almost like 
water, sometimes more or less opaline, and occasionally distinctly tinged 
with blood. 

In many cases, no doubt, inflammation commences at some one spot 
or circumscribed area of the serous membrane ; and, indeed, in mild 
cases it not very unfrequently remains thus limited, or at all events does 
not become general. More frequently the whole of the pericardium is 
involved. 

In the great majority of cases of pericardial inflammation, resolution 
takes place after a longer or shorter period. The fluid which has been 
effused undergoes gradual absorption ; the false membrane becomes organ- 
ized, contracts, hardens, and ultimately is converted into a more or less 
imperfect form of connective tissue. In some instances circumscribed 
inflammatory patches result in the formation of those opaque, white, cica- 
trix-like thickenings which are so commonly met with on the surface of 
the right ventricle, and are known as ' milk-patches.' In some such cases 
the opposed pericardial surfaces become adherent at one or two points, or 
over a small area. But in by far the larger number of cases, when the 
inflammation has been general, the absorption of the fluid and the coming 
together of the inflamed surfaces end in their more or less complete co- 
alescence, and in the obliteration in an equal degree of the pericardial 
cavity. The characters which the resulting adhesions display depend 
largely of course upon the quality and quantity of the false membrane from 
which they have arisen. Sometimes they are thin and delicate, and differ 
little from ordinary connective tissue. Sometimes they are thick, fibrous, 
and perhaps cedematous, and measure then maybe ^ or ^ an inch or more 
in thickness. Sometimes they are almost cartilage-like in density and 
hardness. Sometimes they become the seat of calcareous formations, which 
may constitute bands or patches of considerable extent. 

In the course of pericarditis other results besides those which have been 
enumerated may take place. In some cases the newly formed bloodvessels 
of the false membrane become ruptured, and blood in greater or less quan- 
tity is effused into its substance, or (if the opposed surfaces be not yet 
adherent) into the pericardial cavity. This hemorrhage maybe so copious 
as to cause death. In other cases the inflammation becomes suppurative, 
and the pericardial cavity is converted into an abscess, which may ulti- 
mately contain two or three pints of pus. Suppurative pericarditis is often 
very chronic in its progress, and sooner or later the pus. may point and 
discharge externally in the precordial region, or extend in other directions 
beyond the limits of the pericardium. 

The inflammatory processes of pericarditis, when the attack is slight, 
are probably limited to the serous membrane exclusively ; but when the 
inflammation is intense or assumes a chronic form, it invades the deeper 
tissues, which then get congested and oedematous, and often, if muscular, 
degenerated and enfeebled. Hence it happens that the integuments of the 
precordial region become in many cases distinctly CEdematous ; and it is 



PERICARDITIS. 



461 



perhaps occasionally owing to involvement and consequent enfeeblement 
of the intercostal muscles that the intercostal spaces are observed to bulge. 
It is a more important fact that, in a large number of cases, the outer layers 
of the muscular walls of the heart become to a greater or less depth ob- 
viously degenerated, softened, and weakened. 

Symptoms and progress — The symptoms of pericarditis are so com- 
monly associated with those of the malady in the course of which it arises, 
and with those of endocarditis, which is so often developed in common 
with it, that it is not altogether easy to disentangle them entirely from 
those belonging to these other conditions. Pericarditis is in many cases 
so mild a disorder that it is attended with few or no symptoms of any im- 
portance. In other cases it is one of the most perilous maladies with which 
we have to deal, and its symptoms are correspondingly severe. But, be- 
tween these extremes, cases of all grades of intensity are met with. 

In its mildest form, pericarditis often entirely escapes detection, or is 
recognized only by the accidental discovery of pericardial friction; in most 
such cases, however, there is at some time or other some slight precordial 
pain or uneasiness, together with extension of cardiac dulness and more 
or less obvious febrile disturbance. Most cases of what are termed 'latent' 
and ' dry' pericarditis belong to this group. 

In describing the symptoms of more aggravated cases of pericarditis, it 
will be convenient to divide them into local and general, and to discuss 
these seriatim. The local symptoms are due directly to the condition of 
the pericardium and its influence on surrounding parts. The patient 
generally complains of pain and tenderness in the region of the heart. 
He winces if pressure be made over the prsecordium, and still more if it 
be made in the epigastric region. The pain varies in character, is aching, 
cutting, burning, or a mere sense of soreness, and occasionally extends 
from the heart to the left shoulder and down the left arm. It is usually 
augmented by movement of the diaphragm, and hence the patient tends 
to breathe rapidly, shallowly, and with little abdominal motion. When 
the pain and tenderness are very severe, he usually lies upon his back, 
and, while moving his limbs with tolerable freedom, keeps his trunk almost 
entirely still. The roughening of the pericardial surface which takes 
place at the commencement of the disorder is attended with distinct fric- 
tion sound, the characters of which have already been described. This 
usually commences at the base or apex, or along the right side, but soon 
becomes general ; and having lasted for an uncertain time — a few hours, 
a day or two, or longer — slowly or rapidly vanishes. The further pro- 
gress of the case will alone determine whether this disappearance is due to 
adhesion having taken place, and is therefore permanent, or whether it 
depends on increase of fluid effusion and consequent separation of the 
pericardial surfaces from one another. In the latter case, the friction re- 
appears with the absorption of the fluid, and its final disappearance, due 
to adhesion, is a subsequent event. It must be added that pericardial 
friction-sound is usually rendered more intense by the application of pres- 
sure to the pnecordium, that its intensity is often distinctly modified by 
the movements of respiration, and, further, that pleuritic sounds developed 
along the edges of the precordial region often have a distinct cardial 
rhythm impressed upon them. Other phenomena of more or less import- 
ance which may often be observed are : oedema of the integuments over 
the cardiac region ; a perceptible thrill, arising from the grating of the 
two rough pericardial surfaces upon one another, to be felt by applying 



462 



DISEASES OF THE VASCULAR ORGANS. 



the open hand to the cardiac area ; and more or less complete masking of 
the normal heart-sounds by those of pericardial friction. It is scarcely 
necessary to add that all the phenomena (local and general) which have 
been previously described as belonging to pericardial effusion, are com- 
monly added with typical completeness to those which have now been de- 
tailed, and indeed that they constitute an essential element in the clinical 
description of pericarditis. 

The influence of pericarditis on the action of the heart and on the pulse 
is various. Early in the disease the heart itself may be little affected ; 
more commonly its movements are increased in frequency, and the pulse 
is at the same time harder and fuller than natural. With the increase of 
effusion the beats of the heart become accelerated and diminished in 
strength ; the pulse consequently gets small and feeble, and often irregu- 
lar. Moreover, its rate is peculiarly apt to be increased by any slight 
excitement or muscular effort. 

Among the general symptoms referable to pericarditis are the follow- 
ing : first those of inflammatory fever, namely, increase of temperature, 
dryness of the tongue, thirst, loss of appetite, and scanty high-colored 
urine ; second, shortness of breath, often amounting to dyspnoea or or- 
thopncea, and frequent short, hacking cough ; third, vomiting, a general 
aspect of distress, a look of anxiety, with pinched features and a pallid, or 
sometimes congested, countenance, weariness, want of sleep, tossing of the 
arms, irritability, rambling, and occasionally (especially towards the close 
of fatal cases) maniacal delirium, convulsions, or coma. The latter phe- 
nomena, however, which are certainly not unfrequently associated with 
pericarditis, seem almost invariably to have been observed in cases where 
the pericarditis was distinctly rheumatic, and where, therefore, it is possible 
that they may have been due to some other cause. Tetanic spasms and risus 
sardonicus also have occasionally been noticed in rheumatic pericarditis. 
Further it may be mentioned that in cases attended with much effusion, 
difficulty of swallowing from pressure on the oesophagus, congestion of the 
head and neck from obstruction of the superior cava, and aphonia from 
compression of the left recurrent laryngeal have been observed. 

Recovery from simple pericarditis is attended with the gradual subsid- 
ence of the symptoms which belong to the disease. In slight cases con- 
valescence is often very rapid and complete. Generally, however, when 
there has been much pericardial effusion, and the symptoms have been 
severe, the amendment is slow ; and more or less permanent ill-health is 
apt to remain. Pain, tenderness, cough, difficulty of breathing while the 
patient is at rest, and fever, gradually subside, the patient's appetite im- 
proves, and he begins to enjoy refreshing sleep. But the pulse frequently 
remains for a long while preternaturally quick, or, on the other hand, be- 
comes slow and intermittent, and the precordial prominence and increased 
dulness still continue excessive. Moreover, under these circumstances, 
the patient often remains incapable of taking active exercise on account 
of the persistent ready development of cardiac uneasiness, palpitation, and 
shortness of breath. These symptoms also may in their turn subside more 
or less completely. 

Adhesion of the pericardium can rarely be diagnosed with certainty in 
the absence of a distinct history of pericarditis. It is often attended, how- 
ever, with more or less persistence of enlarged area of dulness, and per- 
manent and unalterable elevation and displacement outwards of the apex 
beat, together perhaps with palpitation, dyspnoea, and some of the general 



MYOCARDITIS. 



463 



symptoms of cardiac disease. Other occasional diagnostic indications are, 
retraction at the apex and of the precordial intercostal spaces during the 
ventricular systole, and an impulse corresponding to the diastole. More- 
over, a pericardium which has once been inflamed is apt, under the influ- 
ence of exciting causes again to become inflamed, notwithstanding the 
complete obliteration of its cavity. 

Pericardial suppuration generally takes a chronic course. The com- 
mencement of suppuration may be attended with rigors and elevation of 
temperature. The former may recur from time to time ; the latter prob- 
ably continues ; and soon the fever assumes a distinctly hectic type. The 
local phenomena are not always very well marked ; there will probably be 
some persistence or increase of pain and tenderness, gradual extension of 
precordial dulness, and augmenting distension of the precordial region, 
with distinct and increasing oedema of the integuments. 

Severe pericarditis not unfrequently ends sooner or later in death. If 
death occur during the height of the disease it may be the result of one or 
other of the cerebral complications which have been enumerated, or of 
asphyxia due to pulmonary complication ; but in the majority of cases it 
is the consequence either of slow asthenia or of an attack of syncope. 
When death takes place at a later period, it is not unfrequently dependent 
on the gradual supervention of the ordinary consequences of heart disease 
— namely, pulmonary congestion with pulmonary apoplexy, or systemic 
venous congestion with anasarca, and affection of the liver, kidneys, and 
other organs. Suppurative pericarditis is generally fatal. 

B. Myocarditis. 

Causation and morbid anatomy — Inflammation of the muscular tissue 
of the heart rarely occurs except in connection with peri- or endocarditis. 
In pericarditis, as we have already pointed out, a greater or less thickness 
of the muscular walls in contact with the inflamed serous membrane is 
often distinctly implicated ; and there is no doubt that their inner aspect 
may be similarly involved during the course of an attack of endocarditis. 
It may even happen that in some situations the cardiac walls become thus 
affected in their entire thickness. Occasionally, no doubt, idiopathic in- 
flammation arises, independently of inflammation of the serous mem- 
branes. It is said, then, to occur chiefly on the left side and towards 
the apex. It may, however, be more or les general. Sometimes pyemic 
abscesses, or abscesses due to embolism, are found studding their substance. 
These are mostly small. But abscesses of considerable bulk have been 
described. 

Inflammation of the muscular tissue of the heart presents the same patho- 
logical phenomena as inflammation of muscular tissue elsewhere. The 
affected parts become injected, there is a tendency to proliferation of the 
stationary protoplasmic elements, and to the escape of leucocytes and red 
corpuscles ; and in connection with these phenomena the muscular fibres 
rapidly lose their striation, become granular and opaque, and break down. 
Not infrequently, indeed, this affection of the muscular fibres, together 
with more or less mottling and softening of tissue, irregularly distributed, 
is the only obvious indication of myocarditis. 

The early effects of inflammation are to diminish the cohesion of the 
affected tissues and to render them less resistant than natural. But subse- 
quently, if resolution do not take place, they become contracted and hard- 



464 



DISEASES OF THE VASCULAR ORGANS. 



ened, and assume a cicatricial character. Under either of these conditions 
especially if the morbid processes be circumscribed, yielding of the affected 
walls may take place, and the foundation of cardiac aneurism be laid. 
When abscesses form they may burst into the pericardium, exciting inflam- 
mation of that membrane ; or into the cardiac cavities, and thus evoke the 
phenomena of embolism or pyaemia. In many cases, no doubt, the in- 
flamed muscle becomes completely restored. 

Symptoms and progress. — It is impossible to assign any specific symp- 
toms to myocarditis. Among those which are most likely to be present, 
are : more or less fever ; debility of the heart with feebleness of impulse, 
of first sound, and of pulse ; tendency to faint ; difficulty of breathing, with 
oppression and uneasiness in the prsecordial region ; and nervous phenomena 
such as restlessness, giddiness, delirium, convulsions, and coma. Death 
usually occurs suddenly from collapse or syncope. 

C. Endocarditis. 

Causation. — The causes of inflammation of the lining membrane of the 
heart's cavities are to a large extent identical with those which excite 
pericarditis and myocarditis. Most of the local causes, however, to which 
pericarditis may be due, can scarcely be operative upon the endocardium. 
Endocarditis is occasionally the result of the accidental rupture of valves 
or chorda? tendinea? ; more commonly it depends on exposure to cold ; but 
by 'far its most frequent cause is the presence of rheumatism. It may also 
be caused by extension from abscesses in the muscular parietes. Again, 
like pericarditis, it is often developed in connection with chorea and scarlet 
fever. A chronic form of endocarditis also may occur in connection with 
the syphilitic cachexia, chronic alcoholism, Bright's disease, and other 
affections inducing persistent dyscrasia. 

31orbid anatomy In the great majority of cases endocarditis is limited 

to the left side of the heart, and to the valves or their immediate vicinity. 
Its presence is indicated by increased vascularity of the affected area? ; in- 
filtration and inflammatory overgrowth of tissue, and consequent increase 
of thickness ; and development of warty growths or granulations upon the 
surface. The thickening, which is mostly attended with opacity and soft- 
ening, varies in degree, and, when it involves the thin curtains of the 
valves or the delicate chordae tendinea?, causes them to become puckered or 
contracted. The granulations are in the first instance mere points ; but 
they soon increase in size, sometimes becoming small bead-like bodies, 
sometimes papillary excrescences, sometimes rounded masses from the size 
of a tare up to that of a filbert. Frequently the neighboring outgrowths 
coalesce to a greater or less extent, forming warty, botryoidal, or cauli- 
flower-like masses, and in some cases pendulous fringe-like but irregular 
processes, which may attain a length of one or two inches. During the 
inflammatory process it is not uncommon for ulceration to take place. If 
this affect the valves it leads to their partial detachment, their attenuation 
at points, and the production of valvular aneurisms, or to their perforation ; 
if it involve the tendinous cords, to their laceration. 

When inflammation attacks the aortic valve the granulations which 
characterize it first appear as a fringe along the festooned inner margins of 
the lunula?, but with the extension of disease they may cover to a greater 
or less extent the whole of the under surface of one or more of the cusps 
and even extend downwards on to the septum. They often, indeed, at 



ENDOCARDITIS. 



465 



length hang from the free edge of the valve, which then usually is thick- 
ened, contracted, and irregular in form. The aortic aspect of the valve is 
rarely the seat of granulations. 

When the mitral valve is inflamed, granulations appear on its auricular 
aspect a little within the free edge, whence they may extend over the 
greater part of that surface and thence on to the auricular walls. With 
the development of granulations there is usually more or less thickening 
and contraction of the free edge of the valve, and at the same time some 
contraction of the valve at its base, in virtue of which the orifice becomes 
diminished in capacity. The chordae tendineae also are apt to be the seat 
of granulations, to undergo thickening and shortening, and to become 
blended to a greater or less extent with the valvular curtains. Granula- 
tions are rarely met with on the ventricular surface of the valve. 

Inflammation, when it attacks the valves on the right side of the heart, 
produces exactly similar effects to those above described. 

Inflammation of the endocardium is not always acute, or always limited 
to the valves. In regurgitant aortic disease the surface of the septum 
ventriculorum, for half an inch or an inch below the valve, generally pre- 
sents more or less cicatricial thickening, and occasionally marked contrac- 
tion. The thickening is the result of chronic inflammation probably due 
to the constantly recurring impact of the refluent blood-stream against the 
ventricular walls in this situation. Again, we occasionally find, especially 
in connection with some forms of so-called 4 atheroma ' of the arteries, the 
lining membrane of the left ventricle studded with irregular patches of 
opaque thickening. These are due to hypertrophy, with more or less 
degeneration, of the endocardium, and are doubtless also of inflammatory 
origin. 

Symptoms and progress The symptoms of endocarditis, apart from 

those of the disease (if any) with which it is associated, and of the lesions 
to which its gives rise, are neither striking nor serious. The symptoms, 
indeed, which are usually ascribed to this affection, are mainly made up 
of those of acute rheumatism and valvular obstruction or incompetence. 
And it must be admitted that it is by the development of the valvular 
lesions, which are an almost invariable accompaniment of endocarditis, 
that we mainly assume its presence and trace its progress. It is needless 
to say that the discovery of valvular mischief is no proof of the presence 
or even of the pre-existence of endocarditis. But if, in the process of any 
one of those diseases of which endocarditis is a common complication, we 
detect a cardiac murmur which had not previously existed ; and if further 
observation proves this to be a permanent phenomenon ; or if changes in 
it indicative of increasing mischief take place ; or if additional murmurs 
become developed ; we cannot reasonably doubt that endocarditis is pre- 
sent. The same conclusion may be fairly arrived at when a young person, 
who is known to have been hitherto healthy, presents vague symptoms of 
ill-health, and reveals under the stethoscope a newly-developed and per- 
sistent valvular murmur. It is very important, however, to note that, in 
forming a judgment w r ith respect to cases of this kind, there are many 
sources of fallacy to be avoided. We must be careful that we do not mis- 
take a pericardial rub for an endocardial murmur : that we do not hastily 
assume that a murmur which we hear for the first time has not existed 
from some previous attack of rheumatism or from birth ; and that we do 
not take a functional or anaemic murmur for one of organic origin. On 
the other hand, we must not too readily take it for granted that, for ex- 
30 



466 



DISEASES OF THE VASCULAR ORGANS. 



ample, in a case of rheumatism, in which the heart is known to have been 
injured in some previous attack, the cardiac disease which we recognize is 
all of old date ; we must not forget that direct murmurs due to granulations 
occasionally disappear ; and, further, we must always recollect that inflam- 
matory vegetations may be formed on the valves, and more particularly on 
the auricular aspect of the mitral, which never impair the action of the 
heart and never give rise to abnormal sounds. 

The remaining indications of the presence of endocarditis are slight 
and fallacious. From the position of the inflamed areae it is scarcely 
possible that precordial tenderness should be present ; and, indeed, it is 
rarely, if ever, observed. More or less uneasiness or pain in the region of 
the heart may, however, be complained of. From the smallness of the 
extent of the inflamed surface, we should scarcely expect much febrile 
disturbance; nor, as a rule, is simple endocarditis attended with marked 
fever. Still there may be elevation of temperature, thirst, scanty urine, 
and other indications of the febrile condition. Again, here, as in peri- 
carditis, we may naturally look for some excitement or other modification 
of the action of the heart. It generally acts more frequently and power- 
fully than natural. 

The prognosis of endocarditis is very serious. It is rare, indeed, for 
perfect recovery to take place. Moreover, the patient remains, for the 
most part, liable to fresh attacks of inflammation, and consequent increase 
of valvular lesion. The results of endocarditis are mainly those which 
have already been considered under the head of valvular disease, and will, 
of course, vary according to the valve affected, and the degree and kind of 
its affection, and need not be again discussed. But it must not be forgotten 
that it is in connection with endocarditis and its local consequences far more 
than with any other form of disease involving the endocardium, that detach- 
ment of solid particles or masses takes place which are conveyed as emboli 
to the brain, liver, spleen, kidneys, lungs, and other organs ; and that the 
liability to this detachment has little or no obvious relation with the se- 
verity of the cardiac lesion. The subject of embolism will be fully dis- 
cussed further on. 

D. Treatment of Inflammation of the Heart and Pericardium. 

In most cases of the several forms of cardiac inflammation which have 
been passed in review, the affection is developed in the course of other 
diseases, such as rheumatism, Bright's disease, and pyemia, for which 
the patient is already under observation. The treatment, therefore, of 
these maladies forms an essential element in the treatment of the heart 
affections which complicate them. It is important, however, to consider 
whether any, and if so what, additional measures may be adopted in refer- 
ence to the cardiac lesions. 

In the treatment of pericarditis the abstraction of blood is generally 
regarded as a most important remedial measure. Blood may be taken by 
venesection from the arm ; but it is probably most conveniently, and best, 
removed from the precordial region by cupping or leeching. To be effi- 
cacious, blood-letting should be performed early, while the symptoms are 
yet acute ; and should be, so far as is compatible with the patient's age 
and condition, free, in order to obviate as much as possible the necessity 
for its repetition. -A dozen or twenty leeches may be applied to the chest 
of an otherwise healthy adult, and the bleeding subsequently encouraged 



TREATMENT OF PERI- AND ENDOCARDITIS. 



467 



by fomentations or poultices. In slight cases at an early period, and in se- 
vere cases after removal of blood, counter-irritation is of considerable value. 
It relieves pain and uneasiness, and probably promotes the absorption of 
fluid. A large mustard plaster, or cotton-wool saturated with turpentine 
or spirits of wine, and covered with some impermeable tissue, may be ap- 
plied to the praecordium ; or iodine paint or blistering fluid may be painted 
over the part ; or simple fomentations, as hot as the patient can bear them, 
may be persisted in. There is, it may be observed, a practical objection 
to the use of applications which blister the surface : namely, that they 
interfere with that frequent examination of the cardiac region which is so 
important. Of the value of opium in this, as in almost all other inflam- 
matory affections, there can be no doubt. It may generally be safely ad- 
ministered, and in large doses ; excepting, perhaps, when the heart shows 
signs of great enfeeblement, when the circulation is embarrassed, the res- 
pirations rapid and shallow, and the skin dusky. When these latter phe- 
nomena supervene, ammonia, ether, alcohol, and other stimulants are indi- 
cated. In order to reduce inflammation, and remove the products of 
inflammation, it was formerly deemed essential to put patients under a 
course of mercury or iodide of potassium. These remedies, however, are 
probably inefficacious except in certain constitutional conditions. Again, 
diuretics and purgatives have been largely advocated for the purpose of 
removing fluid accumulations from the serous cavities. But there is little 
proof that they have any appreciable influence in this respect. It may, 
nevertheless, be useful, when febrile temperature is present, to employ some 
of those agents — namely, aconite, veratrum, or quinine — which are known 
to reduce temperature. But the most efficient means of effecting the re- 
moval of dropsical accumulations is to improve the patient's general health. 
And on this and other grounds it is always important to bring him under 
the influence of tonic treatment as soon as the condition of the digestive 
organs allows of its employment. 

The above remarks as to treatment relate more immediately to pericar- 
ditis. But they are to some extent applicable to endocarditis. It must 
be borne in mind, however, that local bleeding and local medication of all 
kinds are necessarily less efficacious in endocarditis than in the other; and, 
further, that as endocarditis is (except in its remote consequences) a far 
less dangerous and severe affection than pericarditis, a far less active plan 
of treatment is generally needed. 

When, in pericarditis, the accumulation of fluid appears to be seriously 
interfering with the action of the heart, especially if it persist despite all 
treatment; or when we have reason to suspect the presence of pericardial 
suppuration ; the question whether paracentesis should be performed for 
the removal of the fluid will perforce present itself. The operation is one 
which has been performed neither frequently nor with much success ; 
moreover, it is an operation of considerable delicacy and difficulty ; still it 
can scarcely be doubted that it should be attempted under the above cir- 
cumstances. The chief danger to be avoided is that of puncturing the 
heart, the next that of wounding the internal mammary artery. To avoid 
the former danger it is important first to determine accurately the lateral 
boundaries of the distended pericardium, and next to satisfy one's self, by 
the presence or absence of sensible impulse, over what area (if any) the 
heart is in contact with the anterior thoracic parietes, and then carefully 
to make an opening into that part of the pericardium from which the heart 
seems to be remote. The mammary artery runs down behind the costal 



468 



DISEASES OF THE VASCULAR ORGANS. 



cartilages, a little outside the sternum. The most eligible spot for punc- 
ture is usually towards the inner extremity of the fourth or fifth intercostal 
space close to the sternum. It is probably the safest plan to divide the 
soft tissues with the scalpel one by one until the parietal layer of the peri- 
cardium is reached, and then to puncture carefully with a fine trocar and 
canula. If serum escape the entrance of air should be prevented ; if pus, 
it may be advisable to wash out the cavity, and even to inject a weak so- 
lution of chlorinated soda or Condy's fluid. In some cases it may be well 
to make a preliminary puncture with a fine aspirating needle. 



III. MORBID GROWTHS AND PARASITES. 

A. Fatty Growth. 

The presence of a small quantity of fat upon the surface of the heart, 
mainly in the course of the transverse and longitudinal sulci, is extremely 
common, especially in persons who have attained middle life, or who pre- 
sent a general accumulation of fat throughout their connective tissue. This 
condition is of no importance. But occasionally, in persons of great 
obesity, fatty growth becomes excessive, and encroaches seriously upon the 
substance of the heart, not only investing the organ more or less completely, 
but invading the substance of its walls, separating the muscular fibres from 
one another, and imparting to the walls in places (more especially in the 
right ventricle) the softness and general aspect of simple fat. 

The symptoms referable to this affection (which is sometimes described 
as a form of fatty degeneration) are those of cardiac feebleness and incom- 
petence. 

B. Tubercle. 

Tubercle is of infrequent occurrence, and generally takes place in con- 
nection with widespread distribution of the disease. Miliary tubercles are 
occasionally found imbedded in the substance of the muscular walls. Their 
most common seat, however, is the pericardial serous membrane. In this 
situation they may occur in small scattered groups only, or may be thickly 
and pretty generally distributed ; and, especially in the latter case, are 
often associated with more or less abundant inflammatory exudation. 
Cheesy tubercle in considerable masses, and generally associated with 
thick and dense adhesions, is also occasionally observed in the pericardium. 

The symptoms of cardiac and pericardial tuberculosis are generally lost 
in those of more advanced tubercular disease of other organs. If, however, 
they be sufficiently pronounced to attract attention, they are indistinguish- 
able from those of subacute or chronic pericarditis. 

C. Syphilis. 

Syphilitic affection of the heart is not uncommon. The condition which 
is now very generally regarded as such is characterized by the presence of 
fibroid infiltration, of greater or less extent, of the cardiac walls ; with 
imbedded caseous masses, somewha.t closely resembling the so-called 
' knotty' tumors of the liver ; and with more or less indurated thickening 



MORBID GROWTHS OF THE HEART. 



469 



and adhesion of the pericardium. True gummata of recent formation have 
also been observed. Microscopically, the diseased tissues present, as do 
those of gummata developed in voluntary muscles, overgrowth of the in- 
terstitial connective tissue, with more or less fatty or caseous conversion of 
certain parts, in which the involved muscular fibres share. The disease 
may implicate any part of the heart, but most commonly affects the ven- 
tricular walls. Sometimes it forms tumors, which project from the outer 
aspect of the heart, or encroach upon its cavities ; sometimes it leads to 
thinning of certain parts, and to aneurismal dilatation. It must be added 
that fibroid change of the cardiac walls may be due to other causes than 
syphilis, to chronic inflammation for example, and that the specific origin, 
therefore, of all such cases must not be hastily assumed. 

The conditions here spoken of may, at any rate in a clinical point of 
view, be combined. They are chronic in their progress ; and are not un- 
frequently associated with adhesion of the pericardium, lesion of the valves, 
and hypertrophy, dilatation or other modifications of the walls or cavities 
of the heart. The symptoms, therefore, which they induce, although 
liable to considerable variety of detail, are essentially those of chronic 
heart disease, and mainly of those conditions or stages of disease in which 
the heart is enfeebled and incompetent to carry on the circulation effi- 
ciently. Dropsy is of common occurrence, and sudden death not unfre- 
quent. The disease occurs almost exclusively among persons of middle 
or advanced age. 

D. Malignant Disease. 

This affects the pericardium, as it does other serous membranes, only 
much less frequently. It may occur here in the form of miliary granula- 
tions, circular plates, or nodulated outgrowths. It is always secondary, 
and probably never attains sufficient proportions to cause obvious symp- 
toms. Malignant disease of the muscular walls of the heart is also not 
common, and is probably always of secondary origin. Generally it occurs 
there in the form of small imbedded tumors, which are of no practical im- 
portance. Occasionally, however, it forms masses, as large as a hen's egg 
or orange, which encroach on the cavities or orifices of the heart, and 
constitute a more or less serious impediment to the circulation. In some 
instances, sarcomatous and other growths, originating in the posterior 
mediastinum, involve the heart by continuity ; they steal, as it were, along 
the vessels at the base, and then gradually infiltrate the muscular parietes 
of the auricles and ventricles, separating the muscular fibres from one an- 
other, and causing general increase of thickness. In these cases no tumors 
may be developed, and microscopic examination may be needed for the 
detection of the nature of the morbid process which has been going on. 
Among the varieties of malignant disease which have been found involv- 
ing the heart and pericardium may be mentioned scirrhus, encephaloid, 
melanotic cancer, lymphadenoma, and sarcoma. 

Malignant disease of the heart and pericardium has rarely, if ever, been 
diagnosed during life, and indeed rarely gives evidence of its presence by 
symptoms referable to the heart. It is obvious, however, that the symp- 
toms to be looked for are those indicative of cardiac obstruction and weak- 
ness, and that the supervention of such symptoms in the progress of malig- 
nant disease might suggest the possibility of cardiac involvement. 



470 



DISEASES OF THE VASCULAR ORGANS. 



E. Parasites. 

These are very seldom met with in connection with the heart. The 
trichina spiralis has never been found in it. The cysticercus celluloses 
has been discovered there, but not as productive of symptoms. Hydatids 
also have occasionally been observed, varying from the size of an orange 
downwards, and either imbedded in the substance of the muscular walls, 
or occupying the subserous tissue of the visceral pericardium. 

The symptoms to which hydatids would give rise are those: either of 
interference with the due performance of the cardiac functions ; of sup- 
puration, to which such cysts are liable ; of pericarditis, dependent on 
extension from the inflamed cyst, or on its rupture into the pericardium ; 
or, lastly, of the discharge of the hydatid contents into the interior of the 
heart. 

F. Treatment. 

It is impossible to lay down rules in regard to the treatment of cases in 
which the heart is involved in adventitious growths or the seat of para- 
sites. The s} r mptoms which they are likely to induce are mainly those of 
cardiac debility and incompetence, and the treatment must be adapted to 
the symptoms which are present. It may be said, however, generally, 
that diffusible stimulants and tonics are indicated. 



IV. DEGENERATIONS. 

A. Degenerations of the Muscular Walls. 

Causation and morbid anatomy. — We have already pointed out that, 
under the influence of starvation and various wasting diseases, more espe- 
cially phthisis, the heart becomes remarkably diminished in bulk. But 
this change is due to atrophy alone, the muscular fibres undergoing simple 
attenuation, without structural change. 

Of actual degeneration, three varieties are generally described : namely, 
fatty or yellow degeneration, granular or brown degeneration, and fibroid 
degeneration. 

1. Fatty degeneration in an advanced condition is indicated by softness 
of the affected tissues, opacity, a peculiar pale buff color, and, it may be, 
obvious greasiness. Under the microscope, the muscular fibres are found 
to have lost, in a greater or less degree, their natural striation, to be studded 
with minute refractive oily molecules, and to be, as a rule, more friable 
than in health. In the early stage it sometimes happens that the oily 
particles occur only at the poles of the nuclei of the muscular fibres, or 
arranged in longitudinal strings ; but with the progress of the disease they 
get more numerous ; and in extreme cases the fibres lose all their normal 
characteristics and are converted into opaque, irregular cylinders of accu- 
mulated fatty particles. 

Fatty degeneration occurs under various conditions. It is frequently 
the result of inflammation, and when developed in connection with peri- 
carditis occurs more especially in the layer of muscular fibres imme- 
diately subjacent to the visceral pericardium. It is sometimes observed 



DEGENERATIONS OF THE HEART. 



471 



in acute diseases, especially in certain fevers, and in poisoning by phos- 
phorus. We have seen it remarkably developed in a child that died of 
acute purpura. It is a common condition of advanced life, especially if 
this be attended with certain diseases or morbid tendencies, such as heart 
disease, chronic bronchitis, Bright's kidney, hepatic disease, arterial de- 
generation, or gout. It is common also, mainly in old age, as an imme- 
diate consequence of obstructive disease of the coronary arteries or of any 
other morbid condition impairing the vitality of certain portions of the 
organ. 

When the degeneration occurs in connection with inflamed serous mem- 
brane, the affected lamina appears to the naked eye anaemic, and in other 
respects but little altered. When it is due to general disease or to disease 
influencing the heart generally, the whole organ may become pallid and 
softened ; but more frequently the tissues are mottled with fattily degene- 
rated spots or patches — a condition which is very often peculiarly distinct 
in the carnese columnar and on the inner surface of the ventricles. When 
the degeneration is secondary to obstructed arteries, it usually occupies a 
more or less distinctly circumscribed region which presents, as a rule, re- 
markable softness and friability. 

2. Granular degeneration is generally distributed uniformly throughout 
the muscular tissue of the heart, which assumes a brownish hue. The 
muscular fibres are studded with longitudinal strings of brownish particles, 
the exact chemical constitution of which is not known. The circum- 
stances which determine this form of degeneration seem to be the same with 
those to which general fatty degeneration is also due. 

3. Fibroid degeneration affects portions only of the cardiac walls, and 
is comparatively common on the right side. The affected tracts are gray- 
ish, dense, and hard — changes which are due in different degrees to over- 
growth of fibroid tissue and to wasting of the muscular fibres, and their 
conversion into, or replacement by, fibroid tissue. The change is proba- 
bly often undistinguishable from the consequences of syphilis; but is some- 
times a sequela of myocarditis. Again, hypertrophy of the heart, and 
especially that form of it which is secondary to Bright's disease, is often 
made up partly of overgrowth of muscular tissue, partly of overgrowth of 
the intervening connective tissue ; and in some cases the latter element 
becomes disproportionately abundant, and the heart consequently, in a 
sense, degenerate and enfeebled. 

Symptoms — The symptoms of degenerative affection of the muscular 
walls of the heart are mainly those of cardiac weakness and incompetence; 
such especially as dyspnoea, lividity, tendency to syncope, indistinctness 
of the first sound of the heart, and weakness of pulse, which may be quick, 
slow, irregular or variable. To these must of course be added the other 
usual consequences of defective or impeded circulation. Enfeeblement 
from degeneration is one of the recognized causes of sudden death ; and 
it is an important fact that sudden death is liable to occur in those in 
whom degeneration is not yet far advanced, and who have not yet pre- 
sented definite symptoms of cardiac disease. Rupture of the heart is not 
uncommon in those cases in which local softenings from arterial obstruc- 
tion are present. 



472 



DISEASES OF THE VASCULAR ORGANS. 



B. Degenerations of the Valves and Endocardium. 

Causation and morbid anatomy Fibroid, fatty, and calcareous changes, 

or degenerations of the endocardium, are among the most frequent causes 
of heart disease. For the most part they come on with advancing years, 
and may be regarded (with the corresponding conditions of the arterial 
system) as some of the chief consequences and indications of senile decay. 
They are apt, however, to manifest themselves even in early adult life, 
especially in those who have lived intemperate or over-laborious lives, or 
have suffered from syphilis, or are the subjects of chronic Bright's disease. 
They are also apt to supervene on ordinary endocarditis ; and hence it is 
often difficult (except from the history) to distinguish between degenera- 
tive lesions of primary origin and such as are the consequences of bygone 
acute endocardial inflammation. It must be remembered, however, that 
the changes, which are here roughly grouped together as degenerations, 
probably for the most part take their origin in a form of chronic endocar- 
ditis — a subject which will be more fully discussed when we come to speak 
of endoarteritis and degeneration of arteries. 

Degenerative changes may manifest themselves at any point of the en- 
docardial surface ; but far more frequently involve the valves than other 
parts. The lining membrane of the left ventricle is more commonly 
affected than that of the other cavities ; and the aortic and mitral valves 
far more commonly than the valves of the right side. In some cases the 
valves present simply a few opaque, buff-colored (atheromatous) patches ; in 
some they manifest more or less general fibroid thickening — a condition 
which is usually accompanied by a greater or less amount of contraction, 
and often by some fatty or calcareous deposit ; in some cases they are 
rendered thick, nodulated, and irregular, from the accumulation of com- 
bined fibroid, fatty, and' calcareous deposit, and then, if the disease be far 
advanced, project as more or less rigid processes across the orifice to which 
they belong, become blended to a greater or less extent with one another 
at their bases, and reduce the valvular aperture to a mere chink ; in some 
cases, again, the degenerate tissue undergoes erosion, excavations form, 
and finally perhaps the valve gets perforated or ruptured. These changes 
generally are not strictly limited to the valves ; they are apt to be pro- 
longed from the aortic to the aorta or the septum ventriculorum, and from 
the mitral to the chordse tendineae, which become thick, short, and some- 
times incorporated with one another. The chordae tendineae, like the 
valves, occasionally get lacerated. 

Symptoms — It is obvious that the conditions here described may pro- 
duce all varieties of valvular defects, singly or in combination ; and more 
especially the same defects as commonly result from acute endocarditis — 
namely, obstructive and regurgitant disease of the aortic and mitral orifices. 
The changes are chronic, and the symptoms which they induce creep on 
insidiously ; so that it often happens that a patient has had the disease 
upon him for years before its presence is distinctly revealed. Indeed, the 
first clear indication of heart disease is sometimes due to the sudden rup- 
ture of a valve, or some other untoward complication or event ; and we 
are often astonished to find post mortem how extreme a degree of contrac- 
tion of the aortic or mitral orifice has been compatible, not merely with 
life, but with life passed in comparative ease and comfort. 

The early symptoms of degenerative disease of the valves are usually 
vague, comprising, perhaps, some degree of irregularity of the pulse, more 



ANEURISM OF THE HEART. 



473 



or less shortness of breath, occasional neuralgic pain or uneasiness in the 
region of the heart, attacks of giddiness or faintness, and not unfrequently 
more or less impairment of the digestive functions. It must be added 
that, inasmuch as the cardiac affection is usually associated with degene- 
rative changes in the arteries and even in other tissues, the symptoms due 
to these become mingled with those of the heart disease, and may to some 
extent aid our diagnosis of the actual condition of the heart. Among such 
indications may be mentioned the presence of rigid or otherwise diseased 
arteries, as revealed by the condition of the pulse or by cerebral symptoms, 
and the existence of the arcus senilis. The symptoms of the declared dis- 
ease are mainly those of the valvular lesions which have been already fully 
considered. The chief practical point to be remembered is that, however 
slow the symptoms may have been in attaining serious development, the 
morbid processes on which they depend are in the nature of things pro- 
gressive and tend surely to a fatal issue. 

C. Degenerations of the Coronary Arteries. 

The coronary arteries and their branches are peculiarly liable to all 
those degenerative changes which affect the lining membrane of the heart 
and arterial system. Their parietes consequently become thickened with 
fatty or calcareous deposit, and their channels reduced in size or obliterated. 
The latter conditions involve the imperfect nutrition of the parts to which 
the affected vessels lead, and induce those localized fatty changes, attended 
with discoloration of tissue and softening, which have already been ad- 
verted to. 

No specific symptoms can be referred directly to disease of the coronary 
arteries. Angina pectoris has been asserted to occur with special frequency 
in these cases. But it must be recollected that arterial degeneration is 
usually present in a greater or less degree in persons advanced in years, 
and then is usually associated with other cardiac degenerations. 

D. Treatment. 

Degenerative conditions of the heart, as of other organs, call for all 
measures — tonic, alimentary, and hygienic — calculated to maintain or 
improve the general health ; but they also need special precautions and 
special items of treatment, according to the particular phenomena and 
dangers which each case presents. These have been sufficiently indicated 
on an earlier page under the head of the treatment of valvular derange- 
ments. 



V. ANEURISM OF THE HEART. 

Causation. — In addition to that general dilatation of the heart's cavities 
which has been previously considered, partial dilatations or aneurisms are 
occasionally met with. They have been oftener observed in men than in 
women, and for the most part at an advanced period of life. They are not 
uncommon, however, during middle age, and occur, indeed, though with 
extreme infrequency, in children. 

Localized dilatation obviously depends on comparative feebleness of that 



474 



DISEASES OF THE VASCULAR ORGANS. 



portion of the cardiac wall which undergoes dilatation, and its inability to 
resist successfully the internal pressure to which it is subjected. The cause 
of weakness is doubtless different in different cases. In some dilatation 
seems to arise in ulcerative destruction of the lining membrane, or in lace- 
ration and breaking down of more or less of the muscular wall ; but in 
most it is apparently due to the presence of one of those forms of enfeeble- 
ment which have just been passed in review, namely, fatty, fibroid, or 
some other variety of degenerative change. It seems obvious, therefore, 
that it may be a consequence of endocarditis and myocarditis, either in 
their acute or chronic forms, and of syphilis. Not improbably also it occa- 
sionally originates, as do arterial aneurisms, in the effects of very violent 
muscular exertion or of violence inflicted from without. 

Morhid anatomy. — Cardiac aneurisms now and then occur in the right 
ventricle and even in the left auricle, more especially at the foramen ovale; 
but by far their most common seat is the left ventricle. They are gene- 
rally said to affect chiefly the apex of this cavity ; but they may originate 
at any spot within it. In size they range from that of a pea to that of the 
heart itself. In form they may be : a simple hemispherical expansion of 
the apex or some other part ; or flask-like, communicating by a compara-; 
tively small orifice with the ventricular cavity; or sacculated, consisting 
of a series of intercommunicating chambers imbedded in the substance of 
the walls, and extending over a more or less considerable area. Their 
parietes vary in thickness, are sometimes as thin as paper ; and gene- 
rally (especially if the aneurism be of large size or old date) consist, more 
or less completely, of dense fibroid material, with little or no trace of mus- 
cular tissue. Occasionally they undergo calcification. Cardiac aneurisms 
sometimes are empty, sometimes contain laminated or other forms of co- 
agulum. As regards their results, they seem occasionally, after having 
reached a certain size, to remain stationary, or nearly so ; but they tend 
ultimately to undergo laceration, and thus to cause communication between 
the left ventricle and one or other of the auricles, the right ventricle or the 
pericardium. In their progress towards the surface they not unfrequently 
cause pericardial inflammation, and adhesions, which both delay rupture 
and limit its effects. 

Among cardiac aneurisms must be included those of the valves and 
coronary arteries. Valvular aneurisms occur chiefly in the aortic and 
mitral valves, but occasionally in the tricuspid, as the result of inflamma- 
tory or degenerative weakening or erosion ; and they constitute bulgings of 
various sizes, which, in the case of the aortic valve, project into the ven- 
tricle, in the case of either of the auriculo-ventricular valves into the 
auricle, and usually sooner or later rupture, and thus allow of free regur- 
gitation. 

Aneurisms of the coronary arteries are rare. They are generally de- 
veloped in the trunks, at a short distance from the aorta, and form small 
tumors in the transverse sulci. Occasionally numerous small aneurisms 
stud not only the trunks, but also many of the larger branches. Like 
cardiac aneurisms, they may open into the pericardium, cardiac cavities, 
or large vessels at the base of the heart. 

Symptoms Cardiac aneurisms for the most part are never suspected to 

be present until the occurrence of rupture causes either grave symptoms 
of cardiac disease, or death from escape of blood into the pericardial 
cavity. There are no special symptoms by which their presence is indi- 
cated. They are of course frequently attended with some of the usual 



RUPTURE OF THE HEART. 



475 



symptoms of chronic heart-disease , and, no doubt, when the tumor is large 
and so situated as to come into relation with the anterior thoracic parietes, 
the presence of a pulsating tumor distinct from the heart may occasionally 
be recognized. 



VI. RUPTURE OF THE HEART. EFFUSION OF BLOOD 
INTO THE PERICARDIUM. 

Causation Perforation of the muscular walls of the heart may be due 

to accidental or other violence ; with such cases, however, the physician 
has little or nothing to do. Spontaneous rupture is an affection almost 
exclusively of advanced age ; it sometimes occurs in the floor of an aneu- 
rism, sometimes in a heart generally weakened by degenerative changes, 
but more frequently in a circumscribed patch of softening, due to athero- 
matous disease and obstruction of the artery, which supplies it; and it is 
generally immediately traceable to some muscular effort or mental disturb- 
ance. Men are more liable to it than women. 

Morbid anatomy.— Spontaneous rupture occurs almost without excep- 
tion in the walls of the left ventricle, and mostly in front. It generally 
forms in the direction of the muscular fibres an irregular rent, or series of 
rents, which pass irregularly through the walls, and present considerable 
differences of size, form, and position, on the inner and outer surfaces" 
respectively. The lacerated tissue, moreover, is generally infiltrated to 
a greater or less extent with blood. The consequences of laceration of 
the heart, though in all cases death ultimately ensues, present a good deal 
of variety. In some instances (especially in cardiac aneurism) the actual 
rupture into the pericardium is often preceded by the formation of peri- 
cardial adhesions ; in some the rupture occurs primarily into the connec- 
tive tissue beneath the visceral pericardium ; and in both of these cases 
the effusion of blood is at first circumscribed, and the patient may sink, 
not, however, suddenly from copious hemorrhage, but slowly with the 
symptoms of pericarditis. In some instances the rupture occurs directly 
into the pericardial cavity, which then becomes more or less rapidly distended 
with blood. The pericardium is then found post mortem to be full of blood 
— partly serum, partly a bag of undecolorized coagulum in which the heart 
is inclosed, and by which it is concealed ; the heart, moreover, is found 
empty, flattened, and more or less wrinkled on the surface, as if it had 
been subjected to considerable pressure. 

Symptoms and progress — The symptoms of rupture of the heart are 
far from uniform. In a large number of cases the patient is attacked with 
severe pain in the region of the heart, gasps for breath, faints, and dies in 
the course of a few minutes, or even a few seconds. In some cases he is 
also attacked with sudden severe cardiac pain, faintness, and dyspnoea, but 
rallies to same extent ; and then, passing into a condition of extreme col- 
lapse, attended with remarkable feebleness of pulse, coldness of extremi- 
ties, profuse sweats, anxiety and restlessness, sighing respiration or extreme 
dyspnoea, and great oppression, constriction or pain at the chest, dies at 
the end of some hours. In some cases again (and these are they in which 
adherent pericardium or other circumstances delay or prevent the imple- 
tion of the serous cavity with blood) the symptoms which mark the occur- 



476 



DISEASES OF THE VASCULAR ORGANS. 



rence of laceration subside; and the patient returns apparently to a state 
of more or less complete health ; upon which at the end of a few hours, or 
perhaps a few days, either sudden death occurs from the discharge of blood 
into the pericardium, or pericarditis becomes developed, and sooner or 
later carries him off. 

It need scarcely be said that the phenomena which attend the rupture 
of aortic aneurisms into the pericardial cavity are identical with those 
which have just been described. 

Other ruptures of the heart besides those of its outer muscular walls 
may take place ; thus, either the septum of the ventricles or that of the 
auricles may become perforated, the musculi papillares or chordae tendinee 
may be broken, or the aortic, mitral, or other valves torn from their at- 
tachments or split. Such lacerations occur spontaneously probably in those 
cases only in which there has been previous weakening from disease. The 
aortic valve chiefly suffers in this respect, and the tendinous cords of the 
mitral. The consequences of these lesions are obvious : in the first two 
cases, a more or less free communication will be established between the 
auricles or ventricles ; and in the others regurgitation of blood from the 
arteries into the ventricles, or from the ventricles into the auricles will be 
set up or augmented. The symptoms here will be mainly those of advanced 
valve disease ; and the nature of the accident on which they depend may 
possibly be diagnosed, partly by the sudden occurrence or aggravation of 
the patient's symptoms, partly by the circumstances under which this 
sudden occurrence or aggravation took place, and partly by auscultatory 
signs. 



VII. HYDRO-PERICARDIUM. 

Dropsy of the pericardium, like hydrothorax or ascites, is one of the 
incidents of general dropsy. It may depend also on local causes, such as 
obstruction of the coronary veins, and the growth of tubercles or cancer. 
A greater or less degree of it is of common occurrence. The amount of 
serous fluid present rarely exceeds half a pint, and is often not more than 
one or two ounces. It is insufficient, indeed, as a rule, to cause obvious 
symptoms or to be discoverable during life. Hydro-pericardium, however, 
like other varieties of dropsy of serous cavities, may become excessive, and 
hence not only embarrass the movements of the heart, but reveal its pres- 
ence by the physical indications (which have been already discussed) of 
■fluid accumulation in the pericardial cavity. When, however, it becomes 
thus extreme, there is generally reason to suspect its association with some 
degree of pericardial inflammation. 

Hydro-pericardium rarely, if ever, demands special treatment. Counter- 
irritation of the precordial region, and the treatment of the condition on 
which the dropsy depends, are the chief measures to be adopted. It is 
conceivable that paracentesis might be needed. 



SYNCOPE 



— graves's disease. 



477 



VIII. SYNCOPE. 

Causation. — The etiology and symptoms of syncope have been discussed 
in an earlier part of this work, to which we refer the reader. With refer- 
ence, however, to the heart's share in its production we may make a few 
additional observations here. The cardiac failure (which always takes 
place to some extent) is commonly referable to causes, mental or physical, 
operating through the nervous system ; the heart becomes more or less 
completely paralyzed, and contracts feebly or not at all upon its contents. 
In some cases, however, its failure to act depends upon the presence of 
some mechanical impediment to its action, as when it is compressed by rapid 
serous effusion into the pericardium, or by the escape of blood into that 
cavity, or as when sudden obstruction of one of the cardiac orifices by a 
clot or embolus takes place, or the patient is suffering from obstructive 
valve disease. Hearts enfeebled either by dilatation or by fatty or other 
forms of degeneration, or by abundant or dense pericardial false membranes, 
are especially liable to failure of action, and are necessarily more liable than 
others to suffer under the influence of those causes of failure which have 
been previously enumerated. 

Treatment A patient suffering from syncope should be placed in the 

horizontal position, all ligatures should be removed from the neck and 
elsewhere, and he should be freely exposed to cool fresh air. Ammonia, 
or other such stimulants, should be held to the nostrils ; ammonia, ether, 
or alcohol administered by the mouth ; or, if they cannot be swallowed, 
these or turpentine should be given in the form of enemata ; cold water 
should be dashed in the face, either from a jug or by means of a wetted 
cloth or towel, and sinapisms applied to the epigastrium and to the limbs. 
If death seems imminent, it is important to promote the action of the lungs 
and heart by frictions, and it may be necessary to employ artificial respi- 
ration, to stimulate the heart by galvanism, or, if the veins be distended, 
to bleed from the external jugular vein. If syncope be the result of pro- 
fuse hemorrhage, the question of transfusion naturally arises. Whenever 
the syncopic condition assumes a chronic form it is important to maintain 
the bodily temperature and to prevent the patient from making any kind 
of exertion. Then, too, the gradual improvement of the patient's vital 
powers by the judicious exhibition of nourishment, and the assuagement 
of vomiting and all other symptoms which tend to impede this improve- 
ment, become objects of the highest importance. The value of iron and 
other tonics in promoting restoration to health, and of opium or chloral 
hydrate in remedying sleeplessness, excitement, or delirium, need scarcely 
be insisted upon. 



IX. PALPITATION. GRAVES'S DISEASE. {Exophthalmic 

goitre.) 

A. Palpitation. 

The phenomena of palpitation, so far as they involve the heart and 
vessels only, have already been adverted to. They comprise increased 
frequency of cardiac action, suddenness of impulse, together with, not un- 
frequently, some irregularity or intermission. 



478 



DISEASES OF THE VASCULAR ORGANS. 



The symptoms which attend palpitation are throbbing of the heart and 
arteries, noises in the ears, musee, giddiness, faintness, hurried respira- 
tion, precordial uneasiness and anxiety, flushing of face, coldness of ex- 
tremities, clamminess of surface, together with which are often associated 
rushing sounds or murmurs at the cardiac orifices, in the larger arteries, 
and even in the larger veins of the neck. 

The conditions under which palpitation occurs are very numerous. 
Among them maybe mentioned: mental excitement; excessive bodily 
exertion; indigestion; the influence of certain articles of diet or luxury, 
more especially strong tea, and tobacco ; anemia and debility, however 
produced; hysteria; gout; and, besides these, the presence of actual cardiac 
disease. In many of the cases here enumerated the palpitation is occasional 
only, and disappears wholly with the removal of the condition on which it 
depends. But sometimes it assumes a chronic character. The heart is 
then apt to get dilated and hypertrophied ; and these very changes tend to 
maintain or aggravate the conditions out of which they arose. 

B. Graves's Disease. 

Definition The most remarkable cases of persistent palpitation are 

those described by Graves and Basedow, in which, together with palpita- 
tion, there is enlargement of the thyroid body, and exophthalmos or pro- 
trusion of the eyeballs. 

Causation These associated phenomena are most commonly met with 

in young women above the age of puberty ; they are seldom observed in 
girls of younger age, and seldom originate in advanced life. Men are 
affected much less frequently than women. The patients are, in some 
cases, anasmic or hysterical, but by no means invariably so. Sometimes 
the commencement of the disease dates from an attack of fever, or is at- 
tributed to mental shock or over-exertion. Occasionally it ensues on 
organic lesions of the heart. By some it has been contended that the car- 
diac disturbance precedes and is the cause of the goitre and exophthalmos. 
But against this view is the fact that palpitation, more or less long-con- 
tinued, is constantly met with in persons who never have any apparent 
tendency to affection of either the orbit or the thyroid body. Others have 
regarded the goitre as the primary lesion, and have referred the cardiac 
and other symptoms to its influence, exerted either by pressure on the ar- 
teries of the neck or in some less obvious manner. It is sufficient, how- 
ever, in opposition to this view, to point out that Graves's disease is 
sometimes present without thyroid enlargement, and that palpitation and 
exophthalmos are not specially common among the goitrous inhabitants of 
goitrous districts. The proximate cause, indeed, of the disease is very 
obscure. Nevertheless there are many circumstances which render it pro- 
bable that the collective symptoms are due to some affection of the sympa- 
thetic system, which allows of passive dilatation of the vessels of the neck, 
thyroid body and orbit, and at the same time of excited action of the heart. 
Many of the symptoms, in fact, closely accord with those producible either 
by paralysis or by functional disturbance of the sympathetic. Moreover 
various observers have described, in fatal cases of the disease, morbid con- 
ditions of the cervical sympathetic. 

Morbid anatomy, symptoms and progress — The symptoms of Graves's 
disease may come on suddenly or gradually. In the latter case the patient 
probably first complains of violent and frequently repeated cardiac palpita- 



graves's disease. 



479 



tion, together with distressing pulsation of the arteries in the neck. After 
these phenomena have existed for an indefinite period, changes are ob- 
served in the eyes and thyroid body. The affection of the eyes, if not 
actually prior in point of time to that of the thyroid body, is generally per- 
ceived earlier. At first the change is slight, and evident only to those to 
whom the patient's healthy aspect is familiar. The eyes are a little more 
prominent, glistening, and staring than they were. But gradually their 
prominence becomes more and more pronounced, until they protrude so far 
through the eyelids that these are unable to close in sleep, and even at or- 
dinary times are so widely separated that the cornese are visibly encircled 
by the sclerotica. Occasionally even the insertions of the recti muscles 
can be clearly distinguished. The exophthalmos is generally equal on 
both sides. Occasionally, however, it begins unilaterally, and, even when 
both eyes get involved, continues most pronounced on one side. It is a 
curious fact that inflammation rarely attacks the insufficiently protected 
eyeballs; and that sight remains for the most part unaffected, excepting, 
perhaps, that the patient is troubled with muscae, becomes long or short 
sighted, and suffers from fatigue in using the eyes. The protrusion of 
the eyeballs is often variable to some extent, increasing under the influ- 
ence of palpitation, or excitement, and at the menstrual periods; and it 
appears to be due either to accumulation of fat, or of fat with increase of 
connective tissue, in the orbits, or to dilatation of the orbital vessels, or to 
these conditions combined in various proportions. It is often attended 
with aching or throbbing in the orbits, and not unfrequently subsides 
wholly after death. 

The enlargement of the thyroid body is, for the most part, very gradual; 
and attention is generally first directed to it by the continued presence of 
pulsation in the lower part of the neck. It then causes merely a slight 
fulness in the usual situation of the gland, but more especially on the right 
side, and is subject to variations in degree ; sooner or later, however, 
a manifest tumor results. This may be symmetrical or may continue to 
be a little larger on the right than on the left side, but very rarely attains 
a large size, or produces injurious effects by pressure on neighboring 
parts. This form of goitre is generally softer than ordinary goitre, and 
is often attended with a thrill or distinct pulsation, perceptible to the 
patient as well as to the examiner, and with more or less distinct arte- 
rial or venous murmur. It has, indeed, more than once been mistaken 
for aneurism. Its size, like the prominence of the eyes, is liable to change. 

The condition of the palpitating heart varies somewhat. For the most 
part, its action is violent and rapid, and its sounds loud and ringing ; its 
area of dulness is often somewhat increased. In most cases it is at first 
structurally healthy, and so it may continue. Often, however, the persist- 
ence of palpitation induces more or less hypertrophy and dilatation, espe- 
cially of the left ventricle. A functional systolic murmur is not unfre- 
quently audible at the base, and murmurs are often audible also in the 
arteries and veins of the neck. Occasionally, as has been already inti- 
mated, the phenomena of Graves's disease supervene on actual cardiac 
disease ; and it may be added that, in most cases in which post-mortem 
examinations have been made, more or less atheromatous change has been 
detected in the arterial system. 

The phenomena above described are not the only ones that are com- 
monly presented in this affection. It has been especially observed that 
the patient is liable to be irritable, fretful, peevish, incapable of applica- 



480 



DISEASES OF THE VASCULAR ORGANS. 



tion, and to suffer from sleeplessness ; that her appetite is capricious, often 
voracious ; that she suffers from flatulence, and at one time from constipa- 
tion, at another from diarrhoea; that there is a disposition to febrile excite- 
ment, with elevation of temperature by one or two degrees, and that this 
condition may be associated with the presence of Trousseau's ' cerebral 
macula;' and that there is generally amenorrhoea, and not unfrequently 
leucorrhoea. Anaemia and cachexia are also sometimes present. In some 
cases enlargement of the spleen has been observed ; and in some, enlarge- 
ment of the mammas. 

It should be added that, in the early stage of Graves's disease, palpita- 
tion, with throbbing in the vessels of the neck, may be present, without 
obvious thyroid gland or eye affection, and -that in some cases the goitre, 
in some the exophthalmos, may never become developed. 

Graves's disease is not usually dangerous to life. Occasionally, patients 
recover entirely ; more commonly there is partial amendment only ; and 
in a large number of cases the disease is slowly progressive, and at best 
after a while becomes stationary. When death takes place it is mostly 
the consequence of some intercurrent affection, more especially of the 
lungs. In rare cases, the thyroidal tumor causes death by pressure on the 
trachea. 

Treatment There is considerable difference of opinion as to the treat- 
ment of this disease. Some recommend, Trousseau condemns, the use of 
iodine. Iron is generally strongly advocated; both Trousseau and Yon 
Grafe, on the other hand, regard it as injurious. Depletory measures, and 
even the removal of blood, have been lauded. Digitalis, in largish and 
frequent doses is said to be exceedingly valuable in promoting contraction 
of the dilated and pulsatile vessels, and in thus relieving and curing the 
disease. On the same principle, ergot of rye or lead may be supposed to 
be indicated. Belladonna, again, seems to act beneficially. Cold appli- 
cations to the thyroid body and to the praecordial region are said to be very 
serviceable. If the patient be anaemic, or suffer from amenorrhoea, want 
of sleep, or any other condition calculated to cause or maintain ill-health, 
special treatment will, of course, be needed. 



X. CARDIAC NEURALGIA. ANGINA PECTORIS. 

Causation The causes which induce cardiac neuralgia are numerous, 

but, for the most part, such as affect the circulation either through the 
nervous system or by muscular exertion. Among them are : mental ex- 
citement, such as anger, or any sudden impression of pain or pleasure ; in- 
temperance in eating or drinking; active exercise, especially ascending a 
hill or staircase, and straining at stool ; in some cases, even a blast of cold 
air. The attacks are often brought on by mere walking exercise, and not 
unfrequently occur during sleep. Cardiac neuralgia is of frequent occur- 
rence in heart disease and cases of aortic aneurism, and under these con- 
ditions may be met with at any age and in either sex. 

Pathology, symptoms, and progress Neuralgia of the heart is referred 

primarily and mainly to the praecordial region, and occurs therefore chiefly 
to the left of the sternum, but sometimes involves the sternal and right 



ANGINA PECTORIS. 



481 



mammary regions as well. It varies in severity ; is aching, burning, or 
indescribable ; but is generally attended with a sense of constriction, dread 
of breathing deeply, and anxiety. It may radiate down into the lower 
part of the abdomen, up into the root of the neck, or backwards to the 
spine ; but is specially characterized by a tendency to extend to the left 
shoulder, and thence downwards along the inner side of the upper arm to 
the elbow. Not unfrequently it spreads to both shoulders, thence to both 
elbows, and thence again to the wrists and even to the tips of the fingers. 
Occasionally it involves the lower extremities similarly. The abnormal 
sensation which extends along the arms and lower limbs is sometimes an 
aching, sometimes a sense of tightness or constriction, sometimes a tingling, 
and not unfrequently a mere numbness. In connection with these symp- 
toms, the affected limbs, as also the face, suddenly become pale and cold ; 
to which conditions venous congestion and clammy sweats are apt presently 
to succeed. During the height of the attack, the patient often becomes 
giddy and faint, and sometimes falls into a state of insensibility which may 
be attended with convulsions. 

Attacks of cardiac neuralgia vary in their intensity, duration, and fre- 
quency of recurrence, and in the conditions under which they occur. 
They may be so slight as to consist in nothing more than a momentary 
pain or uneasiness in the region of the heart, with some extension of un- 
easiness to one or both shoulders. They may be so severe that the patient 
suffers, and has the appearance of suffering, indescribable agony, with the 
overpowering dread of impending death. He suddenly becomes still, fear- 
ing even to breathe ; clutches whatever is near him for support ; or, assum- 
ing some strange attitude which experience has taught him, grovels on all 
fours, lies upon his chest, or sits astride a chair with his face to the back, 
and his head bent over it. The attacks may last from a few seconds to 
many hours. In the latter case, however, their continuance is due to the 
repetition of paroxysms which are for the most part of no great intensity. 
Sometimes a patient has one attack only ; or he has a succession of attacks 
at intervals, and then no more ; sometimes the first is fatal ; more com- 
monly the affection commences comparatively slightly, with attacks suc- 
ceeding one another at long intervals, but gradually the intervals become 
shorter, and the attacks more severe, and recur on slighter and slighter 
provocation. 

When cardiac neuralgia occurs independently of distinct cardiac lesion, 
it has received the name of ' angina pectoris.' This is rarely met with 
below the age of forty or fifty, and is far more common in men than in 
women. In the majority of cases, too, it has a marked tendency to recur 
at gradually shortening intervals and with increasing severity, and sooner 
or later to prove fatal. Occasionally, however, the disease manifests itself 
in young persons ; and occasionally also (and more particularly in them) 
complete recovery takes place eventually. After death from angina pec- 
toris, various lesions have been detected ; and these (the more important 
of which are calcification of the coronary vessels, and fatty and other de- 
generative affections of the muscular tissue of the heart) have been regarded 
as its cause. In other cases the heart has been found to be perfectly 
healthy. But it is obvious that such lesions as are here adverted to can 
only act, if they act at all, as predisposing causes. What, then, is the 
proximate cause ? It has been assumed to be spasm or cramp of the mus- 
cular tissue of the heart ; and in favor of this view it may be observed 
how intense is the agony which may be produced by the spasmodic action 
31 



482 



DISEASES OF THE VASCULAR ORGANS. 



of the bowels, uterus, or voluntary muscles. The character of the pulse 
has been described as being sometimes weak and scarcely perceptible ; at 
other times, slow, full, and strong. There is reason, however, to believe, 
both from the pallor and coldness of surface which attend the onset of the 
attack, and from sphygmographic observation, that an essential feature of 
the disease is sudden and extreme contraction of the systemic arteries, 
which both prevents the free passage of blood to the capillaries, and, dam- 
ming it up, as it were, in the heart, excites that organ to unwonted but 
more or less fruitless efforts. 

Treatment. — The treatment of cardiac neuralgia, or angina pectoris, 
must be partly prophylactic-, partly directed to the relief of the spasmodic 
attacks. It is of the greatest importance that the patient should avoid or 
obviate all those conditions which are apt to produce the affection ; that he 
should eschew all mental and bodily exertion or fatigue ; and that indi- 
gestion and all other functional derangements should be as far as possible 
prevented by careful attention to diet and appropriate remedial measures. 
For the treatment of the anginal attack various remedies have been sug- 
gested. Among the most valuable are the diffusible stimulants — ammonia, 
ether, and brandy — and narcotics, such as opium and belladonna. During 
an attack, diffusible stimulants are probably the most useful. Faradiza- 
tion to the cardiac region has been attended with good results. Dr. Brun- 
ton, guided by the fact of the spasmodic contraction of the arteries which 
attends, if it do not cause, angina, has tried the inhalation of nitrite of 
amyl (which relaxes the muscular walls of these vessels) during the par- 
oxysm with striking benefit. He applies five or six drops to the nostrils 
on a rag or piece of blotting paper. This method has since been largely 
employed and with marked success. 



XI. CYANOSIS AND MALFORMATIONS. 
A. Cyanosis. 

Causation Lividity or blueness of the skin is a frequent symptom of 

those diseases or conditions in which the due aeration of the blood is in- 
terfered with, and especially, therefore, of some forms of lung and heart 
disease. It may be met with, consequently, in all cases in which impedi- 
ment exists to the passage of air along the larynx or trachea ; in all cases 
also in which there is obstructive disease of the bronchial tubes, whether 
it be bronchitis or any other affection ; and in all cases in which, whether 
from emphysema or other organic lesions, or from pulmonary congestion 
or oedema, the free transmission of blood along the pulmonary capillaries, 
or the free admission of air into the air-cells, is interfered with. It is a 
striking characteristic of cholera; in which disease, either from alteration 
in the blood or from contraction of the smaller branches of the pulmonary 
artery, the blood ceases to pass in quantity through the pulmonary capil- 
laries. Lastly, it is very frequently observed in cases of heart disease, 
more especially of the right side, and in cases of congenital malformation. 

Symptoms and progress — It is in the last class of cases, indeed, that 
the condition commonly known as cyanosis is most frequently present — 
cases in which the blueness first manifests itself at birth, or within a few 



CYANOSIS AND MALFORMATIONS. 



483 



weeks, a few months, or very rarely a few years after that event. We 
shall describe it as it presents itself in these cases. The blueness of sur- 
face varies in depth, but is always most pronounced in the cheeks, lips, 
tongue, and extremities of the fingers and toes. Here the natural rosy 
hue may merely present the slightest possible inclination to purple, or the 
parts may be purple, blue, or almost black. . The general surface is dusky, 
or livid, and ghastly. The tint varies from time to time ; it gets intensified 
under the influence of exertion, mental excitement, exposure to cold, or 
catarrhal or other like affections of the respiratory organs ; and in some 
cases it almost entirely subsides during times of comparatively good health 
and perfect quiescence. The conjunctivae are mostly congested, oedematous, 
and glistening ; the lips, and perhaps the nose and eyelids, are tumid ; but 
the most remarkable degree of tumefaction is always manifested by the 
terminal phalanges of the fingers and toes, which become strikingly thick- 
ened and enlarged, or bulbous. The circulation is feeble, the surface 
(especially that of the extremities) generally cold, and the patient disin- 
clined, and, indeed, unable to engage in active exercise. He is liable to 
parox}''smal attacks of difficulty of breathing, during which his cyanosis in- 
creases, and he not unfrequently passes into a state of syncope ; and he is 
very apt to suffer from congestive and inflammatory affections of the respi- 
ratory organs. He is generally sluggish in body and mind, and his temper 
is for the most part irritable and fretful. Dr. Peacock says that the in- 
ternal temperature of cyanotic patients is not below that of healthy persons. 

Pathology — It was not unnatural to assume that the cyanosis of mal- 
formation is due to the admixture of arterial and venous blood, which 
takes place in the great majority of these cases, through an incomplete 
ventricular septum, a patent foramen ovale, or a persistent ductus arteri- 
osus. But cyanosis has been proved to exist in an intense form in cases 
of malformation where no such admixture was possible, and to be absent 
from many cases of malformation in which the communication between 
the venous and arterial sides of the heart was unusually free. We are 
hence driven to the conclusion that cyanosis must in the main be due to 
the same causes as determine lividity in other forms of heart disease, 
namely, impeded transmission of blood through the lungs, and conse- 
quently insufficient aeration, with over-accumulation of blood in the sys- 
temic veins. If this be the true explanation, it may fairly be asked, What 
are the distinctive marks by which typical cyanosis is distinguishable from 
ordinary cardiac lividity? And it must be acknowledged that the differ- 
ences are of degree or detail only, and are probably due to the fact that 
the veins of young children yield more readily under the continued strain 
to which they are exposed than do those of adults. Cardiac lividity in 
adults rarely attains that depth of color which we often meet with in 
cyanotic children ; and the bulbous enlargement of the fingers and toes 
which is so common in the latter cases is seldom observed as a consequence 
of acquired heart disease. 

B. Malformations. 

Causation and morbid anatomy The subject of cardiac malformation 

is one of great interest and extent, and impossible of adequate discussion 
in a work like the present. Yet it cannot be wholly ignored. We pro- 
ceed, therefore, to make a few remarks upon it. 

The auricles form originally a single cavity, and the separation between 



484 



DISEASES OF THE VASCULAR ORGANS. 



them is effected by the development of a vertical septum, of which the 
fossa ovalis represents the last-formed portion. This septum may be wholly 
absent ; or the fossa ovalis alone may remain more or less patent, as it is 
at birth ; and between these extremes every degree of defect may be ob- 
served. The ventricles, also, constitute, in the first instance, one cavity, 
which, in the course of development, becomes divided into two by the 
growth of a partition from the apex of the organ upwards, the last-formed 
part therefore being that which lies just below the arterial orifices. This 
septum also may be wholly or in part absent. In the latter event the de- 
ficiency is almost always found immediately below the valves. The bulbus 
arteriosus again, in the first stage of its development, is a single cavity 
continuous with that of the common ventricle, and becomes like that, by 
the growth of an independent septum, divided into two portions, of which 
one becomes the aorta, the other the pulmonary artery. It is possible for 
this separation never to be completed ; it is possible that one of the arteries 
may be imperfectly developed or get impervious ; it is possible also for 
them to be transposed, so that the pulmonary artery becomes continuous 
with the left ventricle, the aorta with the right. Further, the ductus 
arteriosus, which is patent up to the time of birth, and allows the aortic 
blood to be distributed freely to the branches of the pulmonary artery, 
may remain patent. Various valvular defects, for the most part causing 
obstruction, are also of frequent occurrence. Lastly, many of these mal- 
formations may coexist, and indeed the appearance of one defect in the 
course of development usually necessitates the supervention of others at a 
later period. 

Defect of either the ventricular or the auricular septum to a slight 
extent does not necessarily allow of any material admixture of venous and 
arterial blood, or involve discomfort or danger to life ; if, however, the 
communication be free, the aerated and non-aerated blood-streams become 
more or less considerably commingled, and serious symptoms may result. 
It is obvious that similar consequences will ensue, in a more or less aggra- 
vated form, under various other circumstances ; as, for example when the 
tricuspid orifice is contracted or obliterated, and all the blood that enters 
the right auricle has consequently to pass through the foramen ovale into 
the left auricle, and thence into the left or it may be common ventricle, 
previous to its distribution ; or when, owing to relative displacement of an 
imperfect septum ventriculorum and of the orifices of the pulmonary artery 
and aorta, both vessels seem to spring from the right ventricle ; or when, 
assuming also the septum of the ventricles to be incomplete, the aorta or 
the pulmonary artery is contracted or impervious, and in the one case the 
pulmonic circulation is affected from the aorta through the medium of the 
ductus arteriosus, in the other the systemic circulation is maintained 
through the channel, afforded by the trunk of the pulmonary artery and 
the ductus arteriosus, between the heart and the descending arch of the 
aorta. 

Symptoms and progress. — In the various forms of malformation which 
have here been passed in review, there is very often some disproportion in 
point of size between the ventricles, and some hypertrophy of their mus- 
cular parietes ; consequently there is generally during life some increase 
of precordial dulness, some modification of its form, and some increase in 
the area and force of the cardiac pulsations. Further, there is, in a large 
number of cases, a more or less loud and rough systolic murmur, audible 
with greatest distinctness over the left third costal cartilage or somewhere 



ARTERIES. 



485 



between this point and the left nipple, and, according to its degree of 
intensity, perceptible over a restricted area only, or over the whole pras- 
cordial region and beyond it. 

The general symptoms which attend malformations of the heart are (if 
certain valves only be affected) those mainly of obstructive disease of those 
valves ; if, however, in addition to valvular obstruction, there be other 
congenital defects, or if, independently of valvular lesions, these other 
defects are sufficiently serious to cause symptoms, the patient presents in 
a more or less aggravated form the phenomena which have been described 
under the head of cyanosis. 

The prospects of life in children born with malformed hearts are very 
gloomy. The great majority die in the first few weeks after birth. A 
small proportion of them survive to the period of puberty. Very few, 
however, who are markedly cyanotic attain adult life. The chief causes 
of death, according to Dr. Peacock, are : cerebral disturbance resulting 
from defective aeration of the blood and congestion of the brain ; and im- 
perfect expansion, collapse, and engorgement of the lungs. 

C. Treatment. 

The treatment of cases of malformation should be mainly hygienic and 
prophylactic. Patients should be protected by warm clothing against 
vicissitudes of temperature, debarred from all active bodily exercise and 
mental excitement, and sustained by nourishing diet. Their digestive 
organs and emunctories should be maintained as far as possible in a 
healthy condition. 



Section II. — DISEASES OF THE ARTERIES. 

I. ARTERITIS. 

A. Periarteritis. 

Causation and morbid anatomy The outer tunic of the arteries, and 

to some extent the middle and even the internal tunic, may be regarded 
as merely modified portions of the general connective tissue. They are 
directly continuous with it, and, as might be supposed, readily share in its 
diseases. Hence, when a district of the body is in a state of inflammation, 
the walls of the arteries which are comprised within it also become in- 
flamed ; and occasionally, indeed, inflammation may attack these more 
violently than other parts, and may travel along them far beyond the limits 
of the primarily affected area. Such inflammation is usually limited to 
the outer tunic, and involves the others (if at all) comparatively late and 
to a slight degree. It is characterized by congestion, infiltration, and 
thickening of the affected parts : is sometimes attended with the develop- 
ment of pus in and around the outer arterial coat ; and occasionally with 
ulcerative destruction or necrosis of the middle and inner coats, and con- 
sequent perforation. From the very slight extent in which usually the 
internal coat is implicated, it but rarely happens that the lining mem- 
brane loses its polish, or that thrombosis takes place. 



486 



DISEASES OF THE VASCULAR ORGANS. 



The symptoms to which this form of arteritis gives rise are more or less 
pain and tenderness, hardness and induration, along the affected vessel, 
and some degree of inflammatory fever. The formation of abscesses, the 
plugging of the artery, and its perforation, would severally produce special 
symptoms. These, however, are matters which will be more conveniently 
discussed hereafter. 

B. Endo arteritis. 

Causation and morbid anatomy. — But, besides that form of inflamma 
tion which commences from without, we not unfrequently meet with inflam- 
mation which originates in the lining membrane, and tends to remain 
limited to that membrane, or at least involves the outer coats later and by 
simple extension only. 

The causes of primary endoarteritis are somewhat obscure. In some 
cases it is due to the irritation of a thrombus or impacted embolus ; in some 
to the effect of long-sustained excessive blood-pressure (as in Bright's dis- 
ease), or to the continued violence of the impact of the blood-stream on 
certain points. It appears, too, in many cases to depend on cachectic con- 
ditions of the system, referable to long-continued exposure, deficiency of 
food, intemperance, syphilis, and the like. Indeed, it may be asserted that 
syphilitic disease of arteries is, at least in many cases, scarcely if at all 
distinguishable from endoarteritis. 

Endoarteritis of the larger vessels is indicated by the development in 
the substance of the internal coat of translucent wheal-like thickenings 
which project, to a greater or less extent, into the vascular channel. They 
have rounded or irregular margins, and often coalesce so as to form patches 
of considerable extent, which then present nodulated surfaces. They may 
be scattered singly in small numbers, or may involve extensive tracts, rend- 
ering the surface of the vessels remarkably uneven ; and they are particu- 
larly apt to appear at the points of bifurcation of vessels, or at the points of 
junction of branches with the trunks from which they spring. When the 
affection is the consequence of thrombosis, and when it occurs in minute 
arteries, it often causes uniform thickening of considerable superficial ex- 
tent. The thickening is due to inflammatory proliferation of the proto- 
plasmic elements of the internal arterial tunic ; and it may be observed 
that, according to Cornil and Ranvier, the acute form of the disease is 
distinguishable from the chronic by the fact that in it the proliferation 
begins at the surface, which is consequently roughened, while in the latter 
it takes place chiefly in the substance of the tunic. After a while, the 
muscular coat becomes involved, degenerates and loses its contractile power; 
and when the inflammation implicates the whole thickness of the vessels the 
walls become generally thick and translucent. 

Syphilitic endoarteritis, more especially as it occurs in the cerebral art- 
eries, has been closely studied by Heubner, who shows : that it begins with 
proliferation of the endothelium; that gradually a growth forms which 
encroaches on the channel of the vessel, and consists of more or less stel- 
late and flattened cells ; that the innermost of these are in close contact 
and arranged as an endothelium, while the outer ones are more loosely 
aggregated, and separated from one another by some amorphous matter, 
and a greater or less number of leucocytes ; that after a time capillary 
vessels, continuous with those of the external arterial tunic, are developed 
in the growth ; and that it ends in cicatricial contraction, and does not, 



DEGENERATION OF ARTERIES, 



487 



like ordinary endoarteritis, undergo fatty change. The morbid process is 
limited to certain arteries, and affects them irregularly. Dr. Greenfield 1 
shows, that the disease may attack the external as well as the internal 
coat, and that it may spread thence to the middle tunic. 

Symptoms Endoarteritis may, as has been hinted, be acute or chronic, 

but there are no special symptoms by which its acuteness or chronicity 
can be distinguished; and, indeed, endoarteritis becomes chiefly import- 
ant and distinguishable by the consequences, mainly mechanical, to which 
it leads. These (which will be elsewhere more fully considered) are refer- 
able to irregularity, rigidity, degeneration and weakening of the arterial 
walls, diminution or occlusion of the channel, dilatation or aneurism, ulcer- 
ation and rupture ; to which may be added the consequences of the depo- 
sition of fibrine upon the roughened surface, and of the formation of gran- 
ulations or pendulous fibrinous polypi. When endoarteritis occurs in super- 
ficial arteries, in consequence of thrombosis or embolism, considerable pain 
and tenderness are experienced in the course of the affected vessel. It 
follows, therefore, that pain may be a symptom of the endoarteritis of 
deep-seated vessels. 



II. DEGENERATION OF ARTERIES. 

Causation and morbid anatomy — Primary fatty degeneration of arte- 
ries frequently comes on with the advance of years. It is recognized by 
the presence of irregular opaque yellowish spots, apparently in the sub- 
stance of the internal membrane, which may be sparsely scattered, or so 
abundant as to produce a general mottling. But although it commences 
in the internal coat, it soon involves the middle coat to a greater or less 
extent. Microscopically it is found that the cells of the affected regions 
are the seat of more or less abundant fatty deposit. They gradually be- 
come entirely destroyed, and with the progress of the disease the inter- 
vening tissues, including the elastic elements and muscular fibres, undergo 
disintegration. 

But more frequently fatty degeneration constitutes a late stage of endo- 
arteritis. The translucent or cartilage-like nodules become more or less 
opaque, generally in their interior, owing to the fatty transformation of 
the cells of which they are in so great a degree composed. And after a 
while the interior of the growth may break down into an opaque pulp, 
containing abundant fatty molecules, degenerate remnants of tissue, and 
cholesterine. A small abscess-like cavity is the result. Or, as in the 
primary affection, the fatty degeneration may commence superficially and 
thence gradually invade the whole of the diseased patch. 

Whether the degeneration be primary, or secondary to arteritis, there is 
a tendency after a while for the degenerated structures to break down and 
be discharged into the vascular channel. When the disintegration begins 
superficially, the affected surface gets eroded, and an ulcer-like cavity re- 
sults. When, on the other hand, the softening mass is at first separated 
from the blood-stream by a layer of coherent tissue, perforation after a 
while takes place, and the escape of the detritus through the orilice results 



'Path. Trans., vol. xxviii. p. 249. 



488 



DISEASES OF THE VASCULAR ORGANS. 



in the formation in the substance of the arterial walls of a flask-like cavity, 
which maintains a free communication with the arterial channel. 

But fatty degeneration is not the only degenerative change which occurs. 
In a large number of cases, more especially chronic cases or those of per- 
sons advanced in years, the precipitation of calcareous matter accompanies 
the fatty process. Calcareous molecules are deposited in the tissues which 
intervene between thefattily degenerating cells; and the result may be the 
formation either of amorphous tuberculated calcareous lumps, or more fre- 
quently of thin, more or less transparent plates, which are curved in con- 
formity with the curvature of the vessel, and which, though usually covered 
in the first instance by a thin membranous lamella, soon get denuded. 
Further, they tend to separate at the margins, and after a time to be shed 
wholly or in part, and to leave ulcer-like excavations behind. Calcareous 
plates may be scattered irregularly and in small numbers, or may be so 
numerous and large as to render the vessel in which they occur a rigid 
bone-like cylinder. 

There is yet another form of calcareous degeneration which is occasion- 
ally met with in arteries of medium and small size. It is not attended 
with, or consecutive to, fatty degeneration, but is due to calcareous trans- 
formation of the muscular cells of the middle coat. The capillary arteries 
occasionally undergo complete conversion into calcareous cylinders. 

The degenerative processes above described, although for the most part 
originating in,. and implicating mainly, the internal coat, tend sooner or 
later to involve the middle coat also ; and, even if this present no visible 
structural change, it becomes after a time more or less impaired as to con- 
tractile power and capability of resistance. With certain exceptions which 
have been specified, degeneration affects the aorta (especially its arch) far 
more frequently than other vessels. Yet none enjoys immunity. The 
pulmonary artery, however, is comparatively rarely affected. 

Symptoms. — The presence of arterial degeneration cannot always be 
recognized with certa'nty. It causes rigidity and therefore loss both of 
elasticity and of contractile power. If superficial vessels be implicated, 
their condition may often be readily recognized by the finger ; if the larger 
and deeper-seated trunks be involved, the loss of their elasticity renders 
the systolic throb of the pulse prolonged and its cessation sudden ; and, 
further, this same loss of elasticity adds to the resistance which the heart 
has to overcome, and tends to induce hypertrophy of that organ. The 
more serious and striking consequences of arterial degeneration are the 
same as have already been adverted to in connection with arteritis, and 
will be best discussed under subsequent headings. 



III. ANEURISM. {Dilatation of Arteries.) 

Definition The terms dilatation and aneurism are of common use as 

applied to diseased arteries. By dilatation we generally mean a uniform 
or somewhat uneven enlargement of the channel of some considerable 
length of vessel ; by aneurism, a comparatively abrupt enlargement of a 
more or less distinctly circumscribed tract. The term aneurism is, how- 
ever, also applied to certain tumors which consist of bundles or convolu- 
tions of simply dilated arteries. 



ANEURISM. 



489 



Causation. — Aneurisms, in the more restricted sense of the word, are 
bulgings caused by the pressure of the blood within vessels on walls which 
have been weakened either by the effects of accidental or other injury, or 
by the progress of the degenerative changes which have just been con- 
sidered. The pressure which the blood within the arteries ordinarily ex- 
ercises on their walls is amply sufficient to cause bulging and aneurism at 
points in which their resisting power is impaired. It need scarcely be 
added that when that pressure is greatly increased, as it is habitually in 
Bright's disease, and intermittently in violent muscular efforts, its effect on 
diseased arteries is necessarily proportionately augmented ; and indeed, 
under some such conditions, tracts of even healthy arteries may undergo 
considerable and permanent dilatation. The influence of violence in the 
production of aneurism is very important, whether we regard it as acting 
through the medium of the blood-pressure, or directly on the vessels by 
strain. Its importance is shown: by the frequency with which aneurisms 
occur in those vessels which from their situation are specially exposed to 
violence ; the frequency with which they occur in those persons whose 
avocations demand excessive muscular exertion ; and the frequency also 
with which the origin of aneurisms is distinctly traced back to some un- 
wonted effort or injury. The starting-point of the aneurism is then some 
laceration, probably of the middle coat, or, if the artery be already dis- 
eased, some injury to the degenerated tissue. But in the great majority 
of cases the aneurism commences in a region already diseased, and prob- 
ably independently of any undue pressure : the passive and enfeebled wall 
slowly yielding before the normal dilating force to which it is subjected. 
The surface left by the erosion of an atheromatous patch, or the detachment 
of a calcareous plate, or the cavity produced by the discharge of a quantity 
of atheromatous detritus through a minute orifice, are all of them frequent 
sites of commencing aneurism. But mere atheromatous change alone, 
apart from actual removal of tissue, especially if the middle coat be involved, 
will cause sufficient enfeeblement to allow of aneurismal expansion. 

Aneurism is a far more common affection in males than in females, 
mainly on account of their different avocations ; and it belongs almost ex- 
clusively to adult life. It is a disease, indeed, chiefly of advanced years ; 
still it not unfrequently occurs both in men and in women, between the 
ages of 30 and 40, and especially in those who have led debauched or hard 
lives, and have suffered from those conditions which produce endoarteritis. 

Morbid anatomy Many needless refinements have been made in re- 
spect of the classification of aneurisms. We shall not waste time upon 
this subject, but will describe them with reference (1) to their form and 
size ; (2) to the constitution of their walls ; and (3) to the nature of their 
contents. 

1. Aneurisms in some cases are mere globose or fusiform dilatations of 
some limited length of artery in its whole circumference. Much more fre^ 
quently they are thimble-shaped or flask-like bulgings, which involve the 
vessel in a portion only of its periphery. In the latter case the orifices by 
which they communicate with the artery vary greatly in size relatively to the 
aneurismal tumors; are round or oval, with the long diameter correspond- 
ing to the axis of the vessel ; and present more or less tumid margins, 
which in large aneurisms, involving nearly the whole width of an artery, 
are distinctly developed above and below only. In other cases aneurisms 
present great irregularity of form. This may be due to the fact, either that 
several aneurismal bulgings have taken place within a short distance of 



490 



DISEASES OF THE VASCULAR ORGANS. 



one another, and have coalesced during their progressive enlargement; or 
that the walls of the primary aneurismal sac have yielded unequally ; or 
that they have ruptured or been destroyed at certain points, and the blood 
has escaped into fresh cavities by laceration, which form diverticula from 
the original aneurism, and remain henceforth portions of it. The configu- 
ration of aneurisms is also greatly determined by the nature, arrangement, 
and resisting power of the structures which surround them and oppose their 
extension. The size which aneurisms attain depends in some degree on 
that of the arteries from which they spring. Aneurisms of the cerebral 
arteries are rarely larger than a walnut, while those of the aorta may vary 
from the size of a pea to that of a cocoanut or a child's head. 

2. Occasionally the walls of an aneurism comprise all the arterial tunics 
in a fairly healthy condition ; as may be seen in fusiform or globose aneu- 
risms due to general dilatation of a certain length of artery. In most cases, 
however, the condition of things is different : — the lining membrane of the 
artery may be traced, often somewhat thickened and pulpy, over the lips 
of the aneurismal orifice, and thence with more or less distinctness over 
the whole inner surface of the aneurism. The external coat also of the 
artery may be traced from without over the whole extent of the aneurismal 
tumor. And as regards the middle coat, while in small aneurisms this 
may often be recognized as a more or less attenuated layer throughout 
their whole periphery, in larger ones it is usually incomplete, either stopping 
short around the orifice, or extending for a short distance into the walls, 
with traces of it still to be detected here and there throughout the rest of 
the circumference. Even when an aneurism commences with perforation 
of the internal membrane of the artery, an adventitious lining forms before 
long, and becomes continuous with that of the artery. And indeed it is 
obvious that in all large aneurisms the laminae, which correspond to the 
inner and outer arterial tunics and are continuous with them, are mainly, 
if not entirely, of new formation. Further, these two coats become, in the 
course of time, identical in structure, and blend, inclosing within them any 
remnants there may still be of the middle coat. Not unfrequently also 
they become the seat of fatty or calcareous change. As an aneurism ex- 
tends, surrounding organs and tissues get involved in it, and take a share 
in the formation of its walls, the proper coats at the same time disappear- 
ing to a greater or less extent. 

3. An aneurismal cavity sometimes remains perfectly free from clot ; 
sometimes, on the other hand, becomes in a greater or lesser degree oblite- 
rated by its slow deposition. The local conditions which favor coagulation 
are roughness of surface and comparative stagnation of blood. Both are 
usually present in perfection in aneurisms which originate in circumscribed 
bulging of an artery, and in which the orifice of communication is com- 
paratively small. In these the process begins with the deposition of a thin 
adherent film upon the surface of the lining membrane. To this other 
films are added in slow succession ; and hence the resulting mass of coag- 
ulum gradually assumes a laminated or stratified character. This process 
may, in fortunate cases, go on until the cavity is obliterated, the last-formed 
laminae forming a kind of irregular bar or septum across its mouth. But 
more frequently the aneurism is obliterated in part only, the coagulum 
being often limited to some diverticulum. When the lining membrane is 
fairly uniform and smooth, and the orifice large in relation to the cavity, 
there is often no attempt whatever at coagulation. And fusiform aneu- 
risms, or aneurisms due to general dilatation, always remain free, or at all 



ANEURISM. 



491 



events never present more than such patches of clot as may be met with 
in an undilated aorta, of which the surface is studded with patches of 
atheroma or calcareous plates. 

The origin of aneurisms in blood-pressure, which the arterial walls are 
incompetent to resist effectually, has already been considered. Their pro- 
gressive enlargement is dependent on the continued operation of the same 
cause. In accordance with a well-known hydrostatic law, the force which 
the blood exerts on a given aneurismal area is exactly equal to that which 
it exerts on an equal area of the artery in its neighborhood ; or in other 
words, the total pressure on the inner surface of an aneurism is in exact 
proportion to the superficial extent of that surface, and has no relation 
whatever either to the size of the orifice or to the form of the aneurism. 
Consequently the larger an aneurism grows, the less capable its walls be- 
come of successfully opposing the blood-pressure within, unless they un- 
dergo some kind of compensative increase of strength. This, however, 
does not necessarily or even commonly occur. 

The effects of aneurisms on the organs in their vicinity are in the main 
those of pressure, and necessarily vary therefore in importance and kind 
according to the situation in which the aneurism is developed. When it 
occurs among easily-displaceable organs it may attain considerable size 
without causing any special mischief or uneasiness. In all cases, however, 
surrounding parts sooner or later get pressed upon ; if they are rigid they 
are gradually destroyed ; if yielding they first yield, and only at a com- 
paratively late period are involved in the aneurismal parietes, and undergo 
the same fate as that to which the unyielding tissues more readily succumb. 
Thus bones and cartilages get gradually eroded ; and their eroded surfaces, 
first exposed in the walls of the aneurisms, presently stand out from them 
into the interior of the cavity. Muscular and other soft tissues are first 
displaced, then flattened and compressed or stretched, and finally incor- 
porated in the advancing wall and lost. Nerves and veins are similarly 
affected — pressure on the former causing pain, spasm, or other functional 
disturbance, and then paralysis or anaesthesia ; pressure on veins producing 
impediment to circulation, with subsequent congestion and dropsy. Simi- 
lar effects of pressure may be exerted on the trachea, oesophagus, and 
intestines, and even on the brain, lungs, liver, and other solid organs, and 
in each case with the production of special symptoms, which we need not 
stop to discuss. 

The results of aneurisms, unless a cure be effected by surgical pro- 
cedure, are almost without exception unfavorable. In a small proportion 
of cases a cure takes place by the spontaneous filling of the cavity with 
laminated clot ; but generally the tumor continues to enlarge, and after a 
time causes death, by implicating some important organ, or by perforation 
and consequent profuse discharge of blood. The latter event may take 
place into one of the serous cavities, in which case the actual opening is 
usually caused by laceration ; or at the cutaneous surface or into one of 
the mucous canals, when perforation is due either to ulceration or to the 
separation of an eschar. Rupture or perforation may also take place into 
the cerebral or spinal cavities, the veins, and even the heart itself. 

Symptoms and progress — The symptoms by which an aneurism may 
be recognized are : first, those which are due to it as a simple tumor; and 
second, those which depend on its relations with other parts. An aneu- 
rism is usually a pulsating tumor. If it be empty of clot its pulsation is 
expansile like that of the arteries, and if it can be grasped the fingers 



492 



DISEASES OF THE VASCULAR ORGANS. 



which inclose it will be sensibly separated at each expansion. If it be 
full of clot no such expansion occurs ; and should pulsation be then felt it 
is merely such as may be presented by any other solid tumor lying upon 
an artery : the aneurism simply follows the movements of the subjacent 
vessel. It is important to know that the mere imparted pulsation of a 
rounded tumor may easily be mistaken for expansile pulsation unless the 
tumor be grasped at its widest part ; for if it be grasped in some narrower 
and more superficial zone, the alternate rise and retreat of the skin-cov- 
ered wedge-like body between the fingers produce exactly the same peri- 
odical and measured separation of them which is so characteristic of true 
pulsation. The comparative hardness, however, of such a mass, and the 
probable fact that it may admit of removal from the influence of the sub- 
jacent artery, will generally correct any erroneous impression. The pul- 
sation of an aneurism is sometimes vibratile, especially if it be situated in 
the neighborhood of the heart and associated with regurgitant aortic valve 
disease. It may be vibratile, however, owing to peculiarities of form and 
the condition of its walls and orifice. 

Aneurisms are often attended with a murmur. This generally corre- 
sponds to the cardiac systole, and therefore to the tidal wave of the pulse, 
and is of a blowing character. It is probably created as a rule in the 
artery, and due either to contraction of its tube at the point of origin of 
the aneurism, or to some irregularity at that part ; but it may be more or 
less modified, or in. some cases developed, by resonance in the aneurismal 
cavity. Murmurs may equally be produced by the pressure of tumors or 
even of the stethoscope upon healthy arteries. Aneurisms of the aortic 
arch, like other aneurisms, are sometimes attended with a murmur syn- 
chronous with the heart's systole, and like them may be free from murmur. 
But here a double murmur is not unfrequent, especially if there be asso- 
ciated regurgitant aortic valve disease. In these aneurisms, again, it is 
not uncommon to hear the two cardiac sounds, or two sounds resembling 
them, even more distinctly than over the heart itself. They have been 
supposed to originate within the aneurism, but are doubtless the normal 
cardiac sounds carried by the blood-stream, and perhaps increased by 
resonance. 

The pulse is often distinctly affected in aneurism. But its affection is 
not so much due to the aneurism itself (though this doubtless has some 
influence) as to the narrowing of the artery, from pressure or disease, 
which is so often associated with aneurism. It is most obvious when the 
aneurism involves either the innominate artery, the subclavian, the de- 
scending aorta, or one of the iliacs. In such cases the pulse in the impli- 
cated limb, as compared with that in the healthy limbs, is diminished in 
volume and strength, and appears to be retarded. The systolic rise is 
slow in attaining its maximum, and the diastolic fall presents a correspond- 
ing character. 

The symptoms due to the direct influence of aneurisms on surrounding 
organs vary in different cases ; but their general character may be gathered 
from the remarks which have already been made. 

Treatment — The treatment of internal aneurisms is far from satisfac- 
tory in its results. The chief object at which to aim is the gradual coagu- 
lation of blood within the cavity, and its consequent obliteration. This 
event occasionally takes place spontaneously in bed-ridden patients or 
those w r ho are prostrated by lingering diseases — under conditions, therefore, 
in which the action of the heart and the circulation are unusually feeble. 



THORACIC ANEURISMS. 



493 



These facts furnish a clue to the general treatment which should be adopted. 
The patient should be kept at as perfect rest as it is possible to enforce. 
He should be exposed to no causes of mental excitement, and strictly de- 
barred from all forms of muscular exertion, including that of straining at 
stool ; if possible, therefore, lie should be confined to his bed. His diet 
should be light and nutritious, and not more abundant than is necessary to 
maintain him in a condition of fair, but not robust, health. It is important, 
too, that the bowels should be kept moderately free, either by enemata or 
by mild laxatives, and at all events not permitted to get constipated ; and 
that all bodily ailments which arise to complicate the aneurism should if 
possible be obviated or cured. Various drugs have been recommended, 
with the object either of quieting the circulation or of promoting coagula- 
tion. Among those which have been employed with reputed success are 
acetate of lead, iodide of potassium, ergot, and digitalis. It may well be 
doubted, however, whether either of these can have any real influence for 
good, and whether indeed digitalis is not likely to be injurious. Reduc- 
tion of the volume of the blood, and of strength, by repeated copious vene- 
sections, was formerly largely advocated ; and it is not improbable that, 
at any rate in some cases, occasional bleedings may be really beneficial. 
To relieve pain or uneasiness opium is invaluable, and as local applications, 
with the same object, ice, belladonna and other sedatives. 

A. Thoracic Aneurisms. 

Morbid anatomy and symptoms. — These occur principally in the differ- 
ent parts of the aortic arch, the descending thoracic aorta, and the roots 
of the large arteries arising from the arch. They spring most frequently 
from the ascending arch, and more commonly from the convexity than 
from the concavity of the arch. They usually form pulsating tumors 
which may be recognized as such if they abut on the surface of the chest, 
especially if also they be large, but which frequently escape recognition in 
consequence of being small or deep-seated. But whether they be posi- 
tively recognized or not, they generally sooner or later induce character- 
istic phenomena by compressing the surrounding organs, and interfering 
with the due performance of their functions ; and end fatally in one of 
several fully recognized modes. It is obvious that the situation of the 
tumor and the facility with which it may be recognized, the parts which 
are specially liable to compression, and the nature of the event, must be 
largely determined by the part of the aorta whence the aneurism springs. 

Aneurisms of that part of the aorta which is embraced by the pericar- 
dium are almost invariably of small size ; and therefore liable to be con- 
founded with simple aortic valvular disease, or degenerative arterial 
changes — with both of w T hich they are commonly associated — or else alto- 
gether to escape recognition. They occasionally open into the pulmonary 
artery, right ventricle or auricle, or superior vena cava ; sometimes lead 
to the production of loculated aneurismal cavities, extending into the sub- 
stance of the cardiac walls or along the auriculo-ventricuiar grooves ; and 
are very apt to rupture at an early period into the pericardial cavity. 

Aneurisms of the rest of the ascending arch often attain a very large 
size. In their growth they encroach, as a rule, on the upper part of the 
right side of the thorax, displacing the lung outwards, and coming in con- 
tact by their anterior surface with the anterior thoracic parietes. Some- 
times they involve both sides of the chest. They not unfrequently also 



494 



DISEASES OF THE VASCULAR ORGANS. 



displace the heart downwards and to the left. According to the amount 
of displacement of the lung or lungs will be the extent of the dulness on 
percussion to which they give rise, and that of their visible pulsation. 
This may be heaving, vibratile, or purring, and if visible to the eye will 
probably be seen to correspond distinctly with that of the heart. As the 
tumor enlarges it causes bulging of the chest-wall over it ; and soon (erod- 
ing the ribs and their cartilages, the sternum, and perhaps the clavicle, 
and at the same time involving the muscular tissue) forms a more or less 
hemispherical pulsating mass. In the interior of the chest it presses upon 
the right lung, which often becomes adherent to it and expanded in some 
degree over it ; and it is apt to compress either the vena cava descendens 
or the left innominate vein, or both — impeding the passage of blood through 
them, or rendering them completely impermeable ; and it may even involve 
the right pneumogastric nerve or the sympathetic trunk. Aneurisms in 
this situation are liable to open externally, into the pericardium or right 
pleura, or into the lung itself and thence into one of the bronchial tubes, 
or even into the right bronchus. 

An aneurism of the transverse arch, if it spring from its front or con- 
vexity, expands chiefly upwards and to the left, so that it presses upon 
and erodes the manubrium of the sternum and the adjoining portions of 
the left upper ribs and cartilages, and clavicle, and forms a tumor which 
occupies the situation here specified, and tends to rise from behind the 
sternum into the root of the neck. If it spring from the concavity or pos- 
terior aspect of the arch, it is often quite latent. If it grow mainly 
upwards and in front, forming a manifest pulsating tumor, it may, like 
aneurism of the ascending arch, attain a large size and eventually burst 
externally ; but much more frequently, owing to the confined limits of this 
portion of the chest and the many important organs which are contained 
therein, it causes death at a comparatively early period from the effects of 
pressure on one or other of those organs. Aneurisms of the transverse 
arch are especially liable to compress the trachea or left bronchus, and 
may also involve the oesophagus ; and often prove fatal by opening into 
one or other of these tubes. They may also compress or destroy the left 
recurrent laryngeal nerve, or the left sympathetic or pneumogastric trunk ; 
or obstruct the left innominate vein. Further, they may rupture into the 
pericardium, left pleura, or lung. 

Aneurisms of the descending arch or of the rest of the thoracic aorta 
are rarely to be detected until they have acquired considerable magnitude. 
They become superficial by destruction of ribs and vertebras in the dorsal 
region to the left of the spine, and there in some cases form pulsating 
tumors of enormous size. But before they cause manifest tumor they may 
sometimes be recognized by the presence of dulness, pulsation, and mur- 
mur, and the absence of respiration, over a limited area. An important 
hint as to their presence is often furnished by the occurrence of more or 
less constant gnawing, aching, or burning pain in the situation of certain 
of the vertebras, and of shooting or aching pains or uneasy sensations in 
the course of some of the nerves of the brachial plexus or of some of the 
intercostal nerves, more particularly on the left side. Aneurisms devel- 
oped in these portions of the aorta, not only tend to cause destruction of 
the bodies of the vertebras and posterior parts of the corresponding left 
ribs, and to involve the dorsal spinal nerves and the sympathetic trunk of 
the same side, but are especially apt to compress the oesophagus and ulti- 
mately to open into it, or to rupture into the left pleura. They may indeed 



THORACIC ANEURISMS. 



495 



rupture into the right pleura. Those arising in the upper part of the chest 
may also compress the trachea, left bronchus, or lung, and eventually open 
into one or other of them. 

It may be convenient to pass in review the various pressure-symptoms 
to which aneurisms of the thoracic aorta give rise, and of which several 
are often present when as yet no tumor can be discovered by auscultation, 
percussion, palpation, or inspection. They are as follows : — 

1. Impediment to the arterial circulation — This may depend either 
directly on the aneurism or on the presence of atheromatous or other 
thickening of the vessels springing from the arch. Not unfrequently the 
artery of one arm alone suffers, and the radial pulse of that arm becomes 
comparatively feeble, or it may be entirely annulled ; sometimes both 
carotid and subclavian of one side are thus affected ; and occasionally all 
the arteries springing from the arch are implicated, so that all visible pul- 
sation in them and their branches ceases. When, however, the impedi- 
ment to the circulation is thus general, it has usually come on gradually, 
and there have been previous stages in which one or two arteries only have 
been involved. In consequence of impediment to the carotid circulation, 
we not uncommonly find patients with aneurism of the arch liable to 
momentary attacks of vertigo, or loss of consciousness, sometimes attended 
with epileptiform convulsions. 

2. Impediment to the venous circulation — When the vena cava or both 
innominate veins are obstructed, the veins at the root of the neck form 
spongy masses immediately above the clavicles, and those of the head, 
neck, arms and upper part of the chest undergo great distension. The 
cutaneous surface gets congested, especially that of the face, the eyeballs 
injected and prominent, and before long the head, neck, and upper extre- 
mities swollen with oedema. The patient suffers also from drowsiness, 
coma, and other cerebral symptoms, and extreme dyspnoea. When one 
innominate vein only is obstructed, the venous distension and oedema are 
limited to one arm and one side of the head, neck, and chest. In this 
case, if the patient's life be prolonged, it is not unusual for remarkable 
clubbing of the fingers of the affected limb to supervene. 

3. Pressure on nerves Pressure on the left recurrent laryngeal nerve 

is soon attended with paralysis of the intrinsic muscles of the larynx which 
it supplies. The left vocal cord becomes motionless midway between the 
position of closure and that which it should assume during ordinary calm 
respiration, and the voice loses its musical character and becomes hoarse 
or whispering. Pressure on the right recurrent, which may be produced 
by innominate or subclavian aneurism, will have a corresponding effect on 
the right vocal cord. It has often been observed that in intrathoracic 
aneurism one of the pupils (as compared with its fellow) is either abnor- 
mally dilated or abnormally contracted. Abnormal dilatation has been 
attributed to pressure upon the sympathetic trunk in the upper part of the 
chest, causing irritation ; abnormal contraction to pressure on the same 
trunk, but sufficient to destroy it or annul its functions. The pneumo- 
gastric nerve is at least as liable as the sympathetic to suffer, and to its 
compression congestion and gangrene of the lungs have been attributed. 
The effects of pressure on the intercostal nerves and brachial plexus have 
already been considered. It may be added that pain is apt to shoot up 
the corresponding side of the neck. It is obvious that the phenomena of 
nervous interference must be looked for chiefly in aneurisms situated to the 



496 



DISEASES OF THE VASCULAR ORGANS. > 



left of the mesial line ; but they occur also in aneurisms of the ascending 
arch, and of course in those of the larger branches. 

Pressure on trachea and bronchial tubes The constantly increasing 

pressure of an aneurism on the trachea, if exerted laterally, displaces it to 
a greater or less extent ; but under any circumstances the pressure sooner 
or later drives that portion of the surface against which it is exerted in- 
wards, first flattening it, and then causing it to bulge so as to reduce the 
tracheal channel at this part to a mere semilunar chink. This process is 
attended with the gradual involvement of the tracheal walls in those of the 
aneurism, and their infiltration with inflammatory products, followed by 
their gradual disintegration and final perforation. While it is going on, 
the patient suffers from more or less stridor of the breath sounds ; which be- 
comes especially audible when, from excitement, exertion, or the act of 
coughing, the respiratory acts are hurried or deepened, and is attended 
with more or less dyspnoea. Gradually these symptoms increase, and cough 
is superadded. The cough is at first occasional and dry, but soon gets 
paroxysmal, and each paroxysm is relieved by the discharge of a small 
quantity of mucus. The stridulous respiration, and the stridulous cough 
in prolonged paroxysms (threatening and sometimes ending in suffocation) 
are peculiarly suggestive of the presence of an aneurism or other tumor in 
the thorax. The suffocative cough is due to the occasional closure by 
mucus of the narrow tracheal chink and the mechanical difficulty which 
there then is in effecting its dislodgment. Hoarseness or loss of the musical 
quality of the voice only exists when, associated with the tracheal pressure, 
there is involvement of the recurrent laryngeal nerve, or some distinct 
affection of the vocal cords or their muscles. Accumulation of mucus in 
the bronchial tubes, lobular pneumonia, congestion of lungs, and pneu- 
monia, are all of them common sequelae of tracheal obstruction. When only 
one of the bronchi is obstructed, feebleness of respiratory murmur and 
imperfect expansion may be observed on the affected side of the chest, on 
which presently supervene rhonchus, crepitation, and other signs of one or 
other of the lung affections just enumerated. 

5. Pressure on the oesophagus causes the ordinary phenomena of oeso- 
phageal stricture. 

Thoracic aneurisms are often exceedingly difficult of diagnosis, partly 
because the symptoms to which they give rise are obscure, partly because 
many affections simulate them in their general and local indications. 
Among such affections may be included : persistent violent palpitation of 
the heart, such as is met with in Graves's disease ; and hypertrophy and 
dilatation of the heart, associated with regurgitant aortic valve disease. 
In both of these conditions there is often violent pulsation, attended with 
purring tremor of the arch of the aorta and large vessels ; and in both, 
marked pulsation ; and the cardiac sounds may be propagated over a con- 
siderable portion of the right infraclavicular and mammary regions. There 
may even be, in the latter case especially, some retraction of the anterior 
edge of the right lung and consequent extension of aortic dulness to the 
right. Other conditions liable to be mistaken for aneurism (especially if 
they be associated with palpitation or heart disease) are mediastinal tumors, 
consolidated portions of lung, and abscesses or growths involving the tho- 
racic parietes. 

In the foregoing account we have referred mainly to typical aortic 
aneurisms. But aneurisms of the intrathoracic portions of the large arte- 
ries which spring from the arch present much the same local and general 



ABDOMINAL ANEURISMS. 



497 



symptoms as do aneurisms arising from the aorta itself in their immediate 
neighborhood. They are to be distinguished mainly by their position and 
the special influence which they exert on the circulation through the ar- 
teries with which they are connected. We may add, that so-called 4 dis- 
secting aneurisms' are not unfrequent in the aortic arch. They are produced 
by the sudden laceration of the diseased or merely thinned internal coat of 
the artery, and the effusion of blood through the rent into the interval 
between the external and internal coats, and generally into the substance 
of the middle coat. The extent to which the dissection may take place, 
and the event, both vary. In some cases the dissection is limited to a 
small well-defined area ; in other cases it circumscribes the vessel, and 
occupies an inch or two of its length ; and in other cases, again, it involves 
the whole length of the aorta. As regards result, dissecting aneurisms 
occasionally undergo spontaneous cure by the coagulation of the extrava- 
sated blood; sometimes they prove fatal by causing complete obstruction of 
the aorta, in the thorax or abdomen ; but more frequently they terminate in 
laceration of the external membrane, and the effusion of blood into some 
cavity, such as the pericardium, or into the connective tissue of the medi- 
astinum or some other part. 

Treatment In addition to the general plan of treatment which has 

been laid down for aneurisms, it is sometimes possible, from the fact that 
aneurisms of the ascending and transverse arch and of the vessels which 
spring from them come speedily into relation with the anterior walls of the 
chest, to employ mechanical or other means to cause coagulation within 
them. The methods which have been had recourse to, but unfortunately 
with very imperfect success, are galvano-puncture, the injection of per- 
chloride of iron or other styptics, and the insertion of coils of thin iron wire 
or of needles. Ligature of the subclavian and carotid arteries, especially 
those of the right side in aneurism of the ascending arch, has occasionally 
proved beneficial ; it is less useful, however, here than in the treatment of 
aneurisms of the roots of these vessels. 

B. Abdominal Aneurisms. 

Morbid anatomy and symptoms. — Aneurisms may be developed in con- 
nection with any part of the abdominal aorta or of its branches within the 
abdomen. Those which chiefly concern the physician are connected with 
the aorta, casliac axis, superior and inferior mesenteries, renals and com- 
mon iliacs. The sources of abdominal aneurisms must be determined by 
their anatomical relations. They may generally, while still of medium 
size, be recognized as distinct pulsatile tumors, attended with more or less 
thrill and often with a murmur. It is easy, however, especially in thin 
persons, to mistake the pulsation of the abdominal aorta for that of an 
aneurism, and especially so to mistake a carcinomatous or other tumor 
situated upon the aorta. Indeed, it is often impossible to distinguish accu- 
rately between an aneurism and such a solid mass, unless by grasping the 
tumor we can distinctly satisfy ourselves that it does not expand, or by 
displacing it from its contiguity with the aorta we annul its pulsations. 
[Before deciding positively as to the true character of an abdominal tumor, 
the physician should cause the patient to assume a position upon his hands 
and knees, and should carefully auscultate his abdomen, and his back along 
the left border of the vertebral column, using when the former region is 
examined a flexible stethoscope. In this position if the pulsation is trans- 
32 



498 



DISEASES OE THE VASCULAR ORGANS. 



mitted from the aorta to a superimposed tumor, it will cease unless indeed 
the tumor is bound down by adhesions ; and so will any murmur that may 
have been previously heard. The murmur and pulsation will persist if 
there be an aneurism or vascular tumor, but a thorough consideration of 
the history and symptoms of the case will usually enable the physician to 
distinguish between these conditions, although the diagnosis of abdominal 
aneurism is confessedly one of the most difficult he is called upon to make.] 
Abdominal aneurisms generally tend to attain a large size, to cause erosion 
of the vertebrae or other bones with which they come in contact, and to 
press upon the stomach, duodenum, or other viscera, veins, or nerves. 
They then cause : pain in the back, which is sometimes very agonizing, 
and often shoots along the branches of the lumbar nerves ; sickness from 
pressure on the stomach or obstruction of the duodenum ; or compression 
and even obliteration of the inferior cava, or one of the common iliac or 
renal veins, with dilatation of the veins of the lower extremities and ana- 
sarca ; or similar conditions in one lower limb only, or in a kidney. Ab- 
dominal aneurisms occasionally burst into the peritoneal cavity, or into 
one of the hollow viscera, or even into the spinal canal. More frequently 
they rupture primarily into the retro-peritoneal tissue ; whence blood may 
be effused round the duodenum, or oesophageal opening of the stomach, or 
into the substance of the mesentery, mesocolon, or great omentum, and 
may thus before the supervention of death cause complete obstruction 
of the cardiac orifice, duodenum, or some other part of the bowel, and 
sometimes the most intense and long-continued agony of pain. 

Treatment The most important of the special modes of treatment of 

abdominal aneurisms are : first, that of putting a ligature round the aorta; 
and, second, that of regulated pressure upon the aorta. The latter method 
may be carried out by the temporary application (say for eight or ten 
hours), under the influence of chloroform, of a specially adapted tourniquet 
to the aorta, if possible on the proximal side of the aneurism. Pressure 
may be applied, with almost equal efficacy, on the distal side. It must not 
be forgotten, however, that the application of sufficiently forcible pressure 
completely to obstruct the aorta is attended with great risk of serious in- 
jury to the abdominal viscera ; and hence it will generally be best to delay 
its employment until the effects of perfect rest have been fully tested. 



Section III. — DISEASES OE THE VEINS. 

I. PHLEBITIS. 

Causation and morbid anatomy Inflammation of a vein is generally 

due : either to the formation of a clot within it, in which case the process 
commences at the inner surface and travels outwards ; or to the involve- 
ment of the vein in inflammatory processes which are going on round 
about it, in which case its walls are invaded from without inwards. Phle- 
bitis, indeed, is almost always secondary. Exceptions to this rule are 
furnished by inflammation of the uterine veins after parturition, and by 
the comparatively rare thickening of the inner coat of veins which corre- 
sponds to the much more frequent thickening of the inner coat of arteries 



VARIX. 



499 



issuing in atheromatous and calcareous degeneration. The presence of 
clots may be regarded as an essential accompaniment of all forms of phle- 
bitis, with the exception of that chronic form last adverted to. 

Inflammation of veins is characterized by thickening of their walls, con- 
nected with more or less active proliferation of the protoplasmic elements 
of their several laminae. The latter process is generally especially active 
in the outer coat, which not unfrequently acquires considerable thickness 
and blends with the surrounding similarly affected connective tissue; and 
scattered abscesses are apt to appear here and there in its course. The 
inner coat tends to become rough, and even to give rise to granulations. 
The contained clot, whether it be formed primarily or secondarily, soon 
fills the channel of the vein and adheres more or less firmly to its inner 
surface. At the same time it tends to lengthen both above and below — 
above to the junction of the vein with the next branch or its communica- 
tion with a trunk vein, below into the tributary branches. The further 
changes which such clots undergo will be considered under the head of 
thrombosis. 

The symptoms of venous inflammation are, if the vein be within reach 
of direct observation, pain and tenderness in its course with more or less 
distinct cylindrical thickening and hardening, and sometimes superficial 
redness. Abscesses in the course of the vessel, communicating or not 
with its interior, are not unfrequent. There is necessarily more or less 
febrile disturbance. The remote effects of phlebitis are on the whole much 
more important than the local effects. They embrace : on the one hand, 
those which are due to venous obstruction — dilatation of the distal veins, 
congestion, and anasarca ; on the other, those dependent on the discharge 
of fragments of thrombus, or of inflammatory or other hurtful matters into 
the circulating blood. These will all be best considered hereafter. 



II. VARIX. (Dilatation of the Veins.) 

Causation — Dilatation of veins is much more common than that of 
arteries, but its causes are a good deal more obscure. It occurs, no doubt, 
generally, in obstructive disease of the right side of the heart ; and (when 
a vein is obstructed) throughout the venous system which is tributary to 
it, as well as in those collateral veins which take on, or divide between 
them, the duties of the defaulting vessel. But in a large number of cases 
veins get dilated and varicose independently of all obstruction, independ- 
ently of overwork, and independently also of obvious degeneration or 
weakening of their walls. 

Morbid anatomy. — When veins dilate they become at the same time 
elongated, and consequently more or less tortuous. The dilatation usually 
commences, and is always most marked, immediately above the valves ; 
and the affected veins assume, therefore, an irregularly moniliform aspect. 
The walls, for the most part, thicken considerably, although presenting 
occasional attenuations, especially over the convexities of the dilated por- 
tions. The thickening is principally due to hypertrophy of the middle 
coat, the attenuation to its atrophy or disappearance. With the progress of 
dilatation the valves become inefficient, and often shrivel up ; calcareous 
plates not unfrequently form in the middle coat ; the connective tissue 



500 



DISEASES OF THE VASCULAE ORGANS. 



around gets thickened and indurated, and blended with the outer coat of 
the vein ; phlebolites are often developed in the pouch-like protrusions ; and 
the last occasionally become perforated either by extension of ulceration 
from without, or by laceration. 

Dilatation may occur either in veins of medium or large size, or in those 
which are ordinarily mere capillary tubes. The former occurrence is ex- 
emplified by the ordinary varicose veins of the lower extremities, and by 
varicocele, the latter by the tuft-like groups so common in the lower limbs 
of pregnant women. Dilatation and varicosity of veins rarely require 
treatment at the hands of the physician. For him they serve mainly as 
important aids to diagnosis. Varicose veins in the lower extremities, vari- 
cocele, and hemorrhoids, are surgical disorders. Dilated or varicose veins 
of internal organs no doubt occur, and aid in the production of functional 
disturbance ; they may even rupture and cause death by hemorrhage. "We 
have witnessed this accident in a case of varicose veins of the oesophagus. 
But their presence can rarely, if ever, be recognized during life. The 
importance of the dilatation of certain groups of superficial veins in enab- 
ling us to judge of the seat and character of internal diseases involving the 
obstruction of deep-seated veins is obvious. 



Section IV.— ARTERIAL AND VENOUS OBSTRUCTION. 

THROMBOSIS AND EMBOLISM. 

Definition. — There are few morbid processes of greater interest and, at 
the same time, of greater practical importance to the physician, than those 
which we are now about to consider. They are the frequent causes of 
many obscure complaints, as well as of some of the most clearly character- 
ized maladies ; they may involve any organ of the body, and present at 
least as many different groups of symptoms as there are organs ; and they 
are intimately related to some of the gravest forms of disease which come 
under our notice, such as pyasmia and puerperal fever. The term ' throm- 
bosis' has been conveniently applied to the coagulation of blood during life 
in the heart, arteries, or veins, and includes within its meaning nearly all 
those cases which were formerly regarded as phlebitic. The term '-embol- 
ism'' has been introduced to designate those cases in which an artery or 
vein gets plugged by the impaction in it of a clot or other solid mass con- 
veyed to it from a distance by the blood-stream. The morbid phenomena 
and symptoms which thrombosis and embolism induce are referable partly 
to local inflammation, but principally to arterial or venous obstruction. 

A. Thrombosis. 

Causation — The causes of thrombosis are mainly : stagnation or slug- 
gish movement of the blood; the contact of the circulating fluid with in- 
flamed or otherwise diseased surfaces ; and special conditions of the blood 
which render it apt to coagulate. 

Morbid anatomy 1. In the heart, after death, the blood which was 

contained within its cavities at the moment of death is generally found 



THROMBOSIS AND EMBOLISM. 



501 



coagulated; moulded to the form of the cavities, and continuous with 
cylindrical clots occupying the trunk veins, and often with similar clots 
extending into the trunk arteries. These clots are sometimes black currant 
jelly-like, sometimes partly decolorized ; and the portions prolonged into 
the arteries are usually more or less purely fibrinous, while those seated in 
the veins are usually soft and black. But not unfrequently the clots con- 
tained in the heart's cavities, and more especially those occupying the ven- 
tricles, are almost entirely fibrinous, more or less opaque and buff-colored, 
close in texture, and even indistinctly laminated. These have for many 
reasons obviously formed during life, probably during the agony; but are 
the consequence of dying and not the cause of death ; and on the whole 
(except from the fact that their deposition helps, as it were, to confirm the 
fatal issue) have little clinical importance. Their presence, however, 
throws light on the development of the peculiar bodies next to be con- 
sidered. It is not uncommon to find, after death, in certain cases that 
rounded buff-colored masses, varying perhaps from the size of a pea to that 
of a walnut, are situated either in the apical portions of the ventricles, or 
in the appendages of the auricles. These, which are sometimes termed 
softening clots, usually occur in groups, are moulded to the surface on 
which they lie, adhere to it, and are continuous with one another by pro- 
cesses which underlie the carneae columnar; so that, with careful dissec- 
tion, they may generally be removed as a continuous whole. They are 
sometimes smooth, sometimes ribbed, upon the surface, and often varie- 
gated in color. On section, they may present a uniform character and 
consistence ; but are more frequently broken down in their interior into a 
thick reddish or yellow pus-like fluid, containing products of disintegra- 
tion only — namely, fat granules, degenerating red and white corpuscles, 
cholesterine, and sometimes hrematoid crystals. The bodies are clots, in 
fact, which have formed in the heart's cavities sufficiently long before 
death to have undergone the degenerative changes which clots formed 
elsewhere also undergo. They may be found in any of the heart's cavi- 
ties ; in one alone, or in two or more at the same time ; but are much 
more common in the left ventricle than elsewhere. The conditions under 
which they are found are various; but they are especially frequent in cases 
of advanced heart or renal disease in which the patient has lain for weeks 
with an extremely feeble circulation, and the balance trembling between 
life and death. During this period the enfeebled heart probably fails to 
empty its cavities completely ; the blood remains stagnant or nearly so in 
those portions of them which are most remote from the direct current ; 
and coagulation takes place either slowly, or more probably suddenly, on 
one of those occasions, which are so common in these cases, when the pa- 
tient falls into a state of apparent death, from which he rallies. Other 
clots of old formation, which may be found in the heart, are laminated 
clots such as occur in aneurisms. They may be present in actual aneu- 
rismal dilatations of the ventricles, and have been discovered behind 
a closely constricted mitral orifice, almost entirely occluding the left 
auricle. 

2. In the systemic veins the coagulation of blood during life is common 
enough. When the venous circulation is simply enfeebled, as in the later 
stages of heart disease, and towards the close of phthisis, carcinoma, and 
other chronic wasting affections, venous thrombosis is of frequent occur- 
rence. It then takes place more particularly in the trunk veins of the 
lower extremities, and in those of the pelvis or at its brim. So again when 



502 



DISEASES OF THE VASCULAR ORGANS. 



some impediment exists to the passage of the blood along a vein, the distal 
portion of the vessel and in a greater or less degree its tributary branches 
fill with clot. When veins are involved in inflammation which is taking 
place round them, this, as has been pointed out, tends soon to pervade the 
entire thickness of the walls, and then to induce coagulation of the blood 
within them and their complete obstruction ; and occasionally, indeed, by 
perforation of the vein or some other process pus or other inflammatory 
products find their way into the interior of the vein or into the substance 
of the thrombus. Thrombosis, secondary to inflammation, is common in 
erysipelas, diffuse cellular inflammation, carbuncle, and the like ; in puer- 
peral pelvic cellulitis ; in inflammation involving the cancellous structure 
of bones, or the walls of the parturient uterus ; and in the venous sinuses 
of the interior of the skull in connection with disease of the internal ear. 

The different characters which venous thrombi display depend largely 
upon their age, and correspond with those presented by cardiac clots. 
When fresh either they have a uniform consistence and color, or there may 
be a central black cylinder, inclosed in a more or less complete fibrinous 
capsule. They do not necessarily at once fill the vessels in which they 
are seated, even if they be in a greater or less degree adherent to them, 
and hence fresh blood tends to insinuate itself between them and the venous 
parietes, and presently to coagulate there. The clots which finally occlude 
vessels thus get more or less distinctly laminated. In their further pro- 
gress venous thrombi undergo various changes. In some cases they blend 
with the venous walls, and, becoming converted into connective tissue, 
cause the obliteration of the vessels ; in some they undergo softening in 
their interior, and conversion into loculated cavities full of fatty detritus 
and caseous remnants of white corpuscles; and occasionally they suppurate 
and form abscesses. 

3. Arterial thrombosis is due in a large number of cases to simple stag- 
nation of blood. Thus the arteries leading to a district, in which (owing 
to morbid processes going on in it) the blood has ceased to circulate, get 
filled secondarily with coagulum. And in precisely the same way, if an 
artery be ligatured, or obliterated at any point by the pressure of a tumor or 
tourniquet, the proximal portion of the vessel up to the nearest branch be- 
comes the seat of thrombosis. Not unfrequently also, when the circulation 
is simply feeble, obliteration of an artery by coagulation of its contents 
takes place. This occurrence in the small branches of the pulmonary artery 
is a common cause of pulmonary apoplexy. It is occasionally also ob- 
served in the arteries of the extremities and even in the aorta itself. Dis- 
eases of the inner coat of arteries — atheroma, calcification, arteritis, and 
syphilis — are all of them liable to induce thrombosis and consequent ob- 
literation. Among the arteries which are especially liable to suffer thus 
are those of the base of the brain and of the extremities. The varieties of 
arterial clots and the changes which take place in them are identical with 
those which have been described in connection with veins. 

B. Embolism. 

Causation and morbid anatomy — The sources of emboli are mainly 
venous thrombi, cardiac vegetations, and disintegrating calcareous, athe- 
romatous, or inflamed surfaces. Additional sources are softening clots 
in the interior of the heart, and morbid growths or other adventitious 
bodies. 



THROMBOSIS AND EMBOLISM. 



503 



The detached solid mass, whatever its nature, is carried along more or 
less rapidly by the blood-stream until it reaches a vessel which is too 
small to allow of its further progress. The point at which it becomes 
finally arrested usually corresponds to the bifurcation of a vessel or to the 
giving off of a comparatively large branch. Here it gets wedged, some- 
times blocking up the channel completely, but more frequently forming at 
first a partial impediment only. In the latter case the constant pressure 
from behind tends to drive it farther and farther onwards, in consequence 
of which, or of the gradual coagulation of blood around it, the vessel be- 
comes at length, as in the former case, completely occluded. Subsequently 
thrombosis takes place on both sides of the embolus ; the artery and its 
distal branches get filled with clot which, gradually undergoing changes, 
blends on the one hand with the arterial parietes, and on the other with 
the embolus. So that although the embolus may, at first, be readily recog- 
nized as an independent body, it often becomes undistinguishable from the 
thrombus to which its presence has given rise. 

Emboli taking their origin in the systemic venous system, or right side 
of the heart, necessarily become fixed in the pulmonary arteries. Those 
which originate in the pulmonary veins, left side of the heart, or larger 
systemic arteries are conveyed to the periphery of the systemic arterial 
circulation. And those, lastly, which are yielded by the veins of the 
chylo-poietic viscera find their resting-place in the branches of the vena 
portas. 

Owing to the infrequency of disease of the valves of the right side of 
the heart, embolism involving the lungs is almost invariably due to the 
detachment of venous clots or fragments of them. In some cases entire 
systems of thrombi become free, and a complete cast, some inches long, of 
a venous tree may be carried into the pulmonary artery and impacted in 
a more or less convoluted form within it. More frequently shorter lengths 
get successively separated and successively lodged in different branches of 
that vessel. It is much more common, however, for venous clots to crum- 
ble as it were gradually away; and for minute fragments to get impacted 
from time to time in the pulmonic arterioles. 

It is rare for thrombosis to take place in the pulmonary veins ; and 
hence embolism is seldom due to this case. The most common source of 
embolism of the systemic arteries is undoubtedly the detachment of granu- 
lations from the diseased aortic or mitral valve ; but another frequent cause 
is the separation of atheromatous or calcareous particles, or other detritus, 
either from the valves or inner surface of the heart, or from the large 
arteries. It is obvious, therefore, that embolism of the systemic arteries 
must in a very large proportion of cases depend on valvular disease, and 
is to be regarded as one of the common risks of that affection. Emboli 
from the various sources just indicated are carried along the aorta and 
thence into some of the smaller branches of the systemic arteries — whither 
is in some degree a matter of accident ; but there are certain parts, namely 
the brain, liver, spleen, and kidneys, and, it may be added, the lower ex- 
tremities, which are specially prone to suffer. It is probable, however, that 
their arteries are not so much specially liable to obstruction, as that their 
obstruction produces particularly serious and obvious ill-effects. The cere- 
bral arteries chiefly liable to obstruction are the middle cerebral branches 
of the internal carotids ; and it is curious that the obstruction generally 
occurs in the middle cerebral of the left side. 



504 



DISEASES OF THE VASCULAR ORGANS. 



C. Consequences and Symptoms of Thrombosis and Embolism. 

It is certain that, whenever a thrombus forms or an embolus becomes 
fixed, inflammation of the implicated vascular walls, if it did not previ- 
ously exist, speedily ensues ; and that hence pain and tenderness will mark 
the course of the vessel if it be within reach of investigation, and more 
or less febrile disturbance generally be present. It is further certain that 
in both cases complete obstruction to the passage of blood through the 
affected vessel takes place very soon if not quite suddenly. It is this fact, 
indeed, which gives to thrombosis and embolism in common their charac- 
teristic features, and Avhich renders it difficult, if not impossible, to make 
any practical distinction between them. In aid, however, of correctness 
of diagnosis it may be pointed out : first, that obstruction of the pulmonary 
and systemic veins by clots can depend on thrombosis only ; second, that 
obstruction of arteries or of the portal veins may be due either to throm- 
bosis or to embolism ; third, that the pre-existence of systemic venous 
thrombosis renders it probable that any obstruction occurring in the pul- 
monary arteries is due to embolism ; and lastly, that the presence of val- 
vular disease on the left side of the heart, or the fact of previous rheuma- 
tism, is presumptive evidence that supervening obstructive disease of any 
of the smaller systemic arteries is of embolic origin. 

The results of venous thrombosis are stagnation of blood in the tribu- 
tary veins with dilatation, soon followed by compensatory dilatation of the 
anastomotic veins, and oedema. These conditions are not secondary to 
thrombosis only, but attend all cases in which veins from whatever cause 
are obstructed. The consequences of arterial thrombosis or embolism, on 
the other hand, are impairment of nutrition of the region which the artery 
supplies, and, following on this, congestion, hemorrhage, inflammation, 
degeneration, or gangrene, together with special symptoms due to the 
organ or part whose integrity is compromised. Similar phenomena neces- 
sarily ensue upon all forms of arterial obstruction, no matter how they are 
produced. The special effects of thrombosis and embolism will for the 
most part be best discussed in connection with the other morbid conditions 
of the several organs in which they occur. There are two or three cases, 
however, which may be most conveniently considered now. They are 
phlegmasia alba dolens, thrombosis and embolism of the heart and pul- 
monary artery, obstruction of the larger arteries of the limbs, and multiple 
embolism of the smaller systemic arteries. 

1. Phlegmasia alba dolens This term is generally applied to the pain- 
ful and osdematous condition of leg which often follows upon parturition. 
An almost exactly similar condition may, however, occur independently 
of parturition, and even in males, and is not unfrequently developed in the 
course of phthisis and carcinoma. The arms also may be affected in like 
manner as the lower extremities. Phlegmasia alba dolens is due to throm- 
bosis of the trunk veins of the limb, or of the larger veins to which these 
converge, which become converted into painful rigid cords. When it fol- 
lows parturition it generally begins from a week to a month after that 
event, and almost invariably in the left lower limb. And even if the right 
become affected it is usually affected in company with the left but at a 
later period. The commencement of this disease is generally sudden and 
indicated by the concurrence of diffused pain throughout the affected 
member, and oedema. The pain varies in character and intensity, and is 
generally attended with soreness or tenderness, sometimes with distinct 



THROMBOSIS AND EMBOLISM. 



505 



hyperesthesia, sometimes with loss of sensation ; and not unfrequently the 
patient is unable, either from pain or from loss of power, to move the limb 
or any of its parts. The oedema gradually inereases until the member 
gets large and smooth, and of a peculiar pale waxy aspect; it does not gene- 
rally pit distinctly on pressure, and often presents remarkable elasticity 
and tension. The superficial veins usually become dilated and unnaturally 
visible ; and the skin often presents a mottled, retiform character, owing 
to the rupture, as in pregnancy, of the deeper layers of the cutis. There 
is not as a rule any manifest change of temperature in the affected limb ; 
but more or less general febrile disturbance is usually present. If there 
be no serious complication, the patient probably recovers at the end of 
three or four weeks. For the most part, however, the veins primarily 
obstructed remain impervious ; and sometimes there is more or less per- 
manence of oedema. 

Treatment Little can be done in the way of special treatment for 

phlegmasia dolens or other cedematous conditions arising from obstructed 
veins. It is generally desirable that the patient be kept at rest, and the 
affected limb elevated or in the horizontal position. If there be distinct 
inflammatory mischief in the course of a large vein, a few leeches may be 
serviceable ; and when oedema and tenderness are present, it is generally 
of benefit to envelop the limb in wadding or flannel, in order to keep it 
warm and promote perspiration. Hot fomentations and baths may also be 
employed. The internal treatment must be determined by the general 
condition of the patient; but for the most part tonics are chiefly indicated. 

2. Cardiac thrombosis It is not easy to specify symptoms by which 

clots formed in the heart during life may be recognized. It is possible of 
course that, from their position, they may occasionally interfere with the 
due action of the valves, and so induce endocardial murmurs ; but it is 
certain that in the great majority of cases they have no such effect. It 
may be taken for granted that their presence must in almost all cases be a 
source of embarrassment to the heart's action, and that they must there- 
fore tend to aggravate the feebleness of circulation out of which they arose, 
and to increase the severity of the cardiac symptoms which the patient 
had previously suffered from. It is important, however, to know that 
when such clots form in the heart, the feebleness of circulation which deter- 
mines their presence there very commonly also determines their formation 
in arteries and veins; and that hence the condition of the lungs and kid- 
neys, connective tissue, and skin, may be of some assistance in the forma- 
tion of a diagnosis. The detachment of such a clot and its entanglement 
in one of the valvular orifices of the heart have been assigned as a cause 
of sudden death. 

3. Embolism and thrombosis of the pulmonary artery We do not 

intend here to discuss the results of that blocking up the smaller branches 
of the artery which is so commonly associated with, and so often the cause 
of, pulmonary apoplexy, lobular pneumonia, circumscribed abscesses, 
patches of gangrene, and the like. Our object is to consider those embolic 
or thrombotic obstructions of the arterial trunk, or of its chief divisions, 
which are occasionally the cause of sudden death. 

It is now well established that the chief danger of thrombosis of the 
larger systemic veins lies in the separation of the whole or a large portion 
of the clot and its impaction in the trunk of the pulmonary artery. This 
accident is especially apt to occur in cases of phlegmasia dolens, and where, 
after parturition, the uterine veins have become plugged. The patient, 



506 



DISEASES OF THE VASCULAR ORGANS. 



probably in the midst of apparently fair health, is suddenly seized with 
severe pain in the region of the heart, attended with intense distress and 
gasping for breath, pallor or lividity of face, and extreme feebleness or 
even suppression of pulse, and dies collapsed. It has been disputed whether 
death is due to asphyxia or syncope. It is certain, however, that the 
sudden obstruction of the pulmonary artery causes ' shock,' or collapse, 
and that the patient sometimes dies of this shock within a few seconds ; 
and it is further certain that the symptoms of sudden obstruction are often 
undistinguishable from those of angina, or rupture of an aneurism, or of 
the heart itself, into the pericardial cavity. Indeed, the symptoms of 
pulmonic obstruction are by no means typical ; and its diagnosis must 
depend mainly on the association of the symptoms above described with 
those conditions of the venous circulation which are known to be pro- 
ductive of embolism. 

There are two or three points, however, in relation to this subject which 
demand a word or two of comment : First, sudden obstruction of the pul- 
monary artery by an embolus, even if attended with symptoms of great 
severity, does not necessarily end in immediate death. The clot may be 
driven onwards into a branch, the symptoms of impending death subside, 
and the phenomena due to the obstruction of a branch only presently 
ensue. Second, it is important to bear in mind that many of the recorded 
cases of sudden death from pulmonary embolism are cases in which the 
only foundations for this diagnosis were : suddenness of death, possibly 
from syncope ; and the discovery after death of an ordinary fibrinous clot 
in the right ventricle, prolonged thence into the pulmonary artery and its 
branches — a clot originating in the spot in which it was found, and the 
consequence of dying, not the cause of death. Third, thrombi sometimes 
form in the larger branches of the pulmonary artery. Occasionally, in- 
deed, the trunk and the greater number of its ramifications are almost 
entirely occluded by them. It is a fact that these may form without pain, 
and cause little or no distress, until, by some little displacement of them, 
or by the sudden coagulation of the blood still circulating between them 
and the walls of the tubes in which they lie, they suddenly bring the pul- 
monary circulation, and with this life itself, to a stop. 

4. Embolism and thrombosis of the larger systemic arteries It some- 
times happens that, from either embolism or thrombosis, one or more of 
the arteries of the legs, the femorals, the iliacs, or the abdominal aorta 
itself, become obstructed. And the same thing may occur in respect of 
the arteries of the upper extremities. The immediate result is serious 
impediment to the circulation through the implicated limb or limbs, char- 
acterized by cessation, or, at any rate, diminution of pulsation in the ves- 
sels beyond, and more or less pallor and coldness. In some cases collateral 
arteries gradually enlarge, and the general condition of the limb after a 
time becomes normal. In other cases the circulation comes generally, or 
in certain areae, to a permanent stand-still, the affected parts gradually 
lose their temperature, the surface gets pallid but mottled with purplish 
spots, and the tissues assume a doughy consistence, bullae, filled with sani- 
ous fluid, soon rise upon the discolored patches, and gangrene becomes 
established. Arterial embolism is generally attended with severe pain at 
the point of impaction, and much pain and tenderness are generally pres- 
ent in the course of plugged arteries. It usually happens, moreover, that 
pain and tenderness are, for a time at least, present in a greater or less de- 
gree in the parts which are in process of sphacelation. 



THROMBOSIS AND EMBOLISM. 



507 



Treatment. — For the local treatment of gangrene little can be done 
beyond keeping the parts warm. For this purpose they may be greased 
and covered with cotton-wool or wadding. For general treatment it is 
chiefly important to maintain the patient's strength by the administration 
of food and stimulants, aided by tonics ; and to relieve pain and distress 
by opiates. 

5. Multiple embolism of the smaller systemic arteries — This is usually 
the consequence of ulcerative endocarditis, or of the gradual erosion and 
disintegration of parts of the endocardium — mainly the aortic and mitral 
valves — which have been the seat of inflammatory thickening and over- 
growth. It may come on in the course of acute rheumatism as a compli- 
cation, or it may supervene accidentally, so to speak, in persons suffering 
from chronic heart disease. 

It depends on the constant or repeated discharge into the blood-stream 
of minute fragments of detritus, or emboli ; which, distributed throughout 
the system, obstruct the smaller arteries, and mainly those of the kidneys, 
spleen, and liver — causing infarcts, with more or less attendant inflamma- 
tion, which is apt to spread from the solid organs to the serous membranes. 
The exact nature of the embolic changes occurring under the above cir- 
cumstances in different parts of the organism has been described in the 
article on pyasmia, and will be further considered in connection with dis- 
eases of particular organs. 

The symptoms of this condition have a close resemblance to those of 
pysemia, but, on the whole, are less intense, and less rapidly terminate in 
death. The patient generally has rigors, with elevation of temperature, 
up, it may be, to 105 or more, and perspirations. The febrile symptoms 
intermit, sometimes several times a day. The respirations increase in fre- 
quency ; the pulse becomes rapid and feeble or irregular ; the tongue gets 
coated; anorexia, thirst, nausea, or sickness, and oftentimes diarrhoea en- 
sue ; the spleen generally enlarges and gets distinctly tender ; occasionally 
more or less jaundice supervenes ; the urine frequently contains albumen ; 
the patient becomes restless, delirious, or drowsy, and sometimes at length 
comatose. In addition, inflammations of the joints or serous membranes, 
and roseolous, petechial, or pustular rashes are occasionally developed. 
The collective symptoms, nevertheless, are very often vague and mislead- 
ing, and are liable to be mistaken, not only for those of pyaemia, but for 
those of enteric fever or ague. Most frequently, no doubt, the disease 
chiefly simulates chronic pyaemia ; and if its source in cardiac disease 
were overlooked, would be taken for pyaemia. Its resemblance to ague 
is occasionally very remarkable. In a case recently under our care, 
which lasted altogether several months, the main symptoms were typical 
ague-like paroxysms, coming on almost without exception twice in the 
twenty-four hours, and separated by intermissions of complete apyrexia, 
associated with gradual failure of strength, and drowsiness finally passing 
into coma. 

Slight attacks of this affection doubtless occur not unfrequently, are 
recovered from, and overlooked; but where it is present in an aggravated 
form it is probably always fatal sooner or later, and generally perhaps in 
the course of two or three weeks. 

For treatment little can be done, beyond relieving symptoms, reducing 
fever, and maintaining the patient's strength. 



508 



DISEASES OF THE VASCULAR ORGANS. 



Section V. — DISEASES OF THE DUCTLESS GLANDS, 
BLOOD, &c. 

I. DISEASES OF THE THYROID BODY. 

To diseases of this organ the term ' goitre' or 1 bronchocele' is com- 
monly applied. It is more convenient, however, to restrict these names 
to a certain group of hypertrophic affections than to include under them 
every variety of lesion to which the thyroid body is liable. 

The chief affections which would on these grounds be excluded are in- 
flammation and carcinoma. 

Idiopathic inflammation of the thyroid body is certainly of unfrequent 
occurrence; it may, however, follow secondarily upon goitre, or result 
from operation, or injury inflicted upon the gland. It is probable also 
that some of the overgrowth of the hypertrophic organ may be due to 
chronic inflammation. 

Carcinoma of the thyroid body is extremely rare. Undoubted examples 
of this affection have however been recorded, in some of which the morbid 
growths were primary, in others due to extension from neighboring organs, 
in others secondary in the usual sense of that term. 

It is needless to discuss particularly the symptoms to which these con- 
ditions give rise, or the special treatment they may require. 

A. Goitre. {Bronchocele.) 

Causation The circumstances under which goitre arises are various 

and not very clearly understood. There is no doubt that it is far more 
common in females than in males ; and indeed, as regards women, it has 
long been known that there is not unfrequently a tendency to some tempo- 
rary enlargement of the thyroid body both during pregnancy and at the 
catamenial period. It is occasionally observed in the foetus, and is then 
commonly associated with some peculiarity in the form and situation of 
the gland. 

Goitre appears to originate with special frequency between the ages of 
eight and puberty ; but rarely, if ever, after forty. It occurs in a sporadic 
form in probably all parts of the globe ; that is, isolated cases, for which 
no cause can be assigned, are nearly everywhere occasionally met with. 
Jt is remarkable, on the other hand, that goitre is endemic in many limited 
areas scattered nearly all over the world. Such places are, in England, 
met with in Derbyshire, Hampshire, Nottinghamshire, Sussex, and York- 
shire. Goitrous districts are as a rule of peculiar geological formation ; 
they are mostly valleys ; and usually their soil, or that of the adjoining 
mountain ranges, is formed largely of lime or magnesian limestone ; and 
the water of the wells or watercourses w r hich traverse them is largely im- 
pregnated with carbonate or sulphate of lime, with which in a considerable 
number of cases magnesia is associated. Various reasons have been as- 
signed for the prevalence of goitre in these localities. All evidence, how- 
ever, seems to point to the drinking water as the efficient agent in its 
production ; and it is generally held that the poisonous ingredient is either 
sulphate or carbonate of lime, or both, in combination probably with mag- 
nesia. The main objection to this view — and it is a serious one — is, that 



GOITRE. 



509 



hard waters containing such ingredients in excess occur and are used in 
non-goitrous localities by persons who never become goitrous. And hence 
it is probable, as is suggested by Virchow, that these salts do not act 
directly, but that associated with them there is some other principle of a 
malarious character to which the goitrous tendency is essentially due. It 
may be added: that endemic goitre is endemic in the strict sense of the 
term; that it belongs, as it were, to the locality; that new-comers are 
liable to suffer equally with those who have been born and bred in it (allow- 
ance being of course made for the relative length of their exposure to the 
goitrous influence) ; and that, although the children of goitrous parents 
become in large proportion goitrous in such localities, the tendency is not 
hereditary, and ceases in them when they are removed from the influence 
of the poisonous principle. In goitrous districts the disease is not limited 
to man ; but dogs, mules, and horses are all liable to suffer. 

Morbid anatomy Goitre consists in a kind of hypertrophy of the 

normal constituents of the gland — namely the bloodvessels, connective 
tissue, and groups of intercommunicating vesicles forming the ultimate 
lobules which the connective tissue circumscribes. In some cases all of 
these become increased in equal proportion, and the goitre then differs 
little if at all, except in bulk, from the healthy organ. More frequently, 
however, one of these constituents undergoes disproportionate development, 
and hence the texture of the tumor becomes characteristically modified. 
Thus, sometimes the connective tissue alone undergoes hypertrophy, and 
the tumor gets hard and dense ; sometimes the vascular tissue especially 
becomes preternaturally developed — the veins and arteries, or more fre- 
quently the veins alone, attaining comparatively enormous dimensions ; 
sometimes the vesicles are the chief seat of change — they become dilated 
and filled with an albuminous fluid, or a solid albuminoid or gelatinous 
substance. Such cysts, partly by simple dilatation, partly by coalescence, 
may attain the size of a pigeon's or hen's egg, or even a larger bulk. In 
a case recorded by Mr. Spencer Watson, a cyst of this kind yielded on 
puncture a pint and a half of blood-colored fluid. It must be added : that 
cysts of considerable size may be developed in glands which are in all 
other respects healthy ; that a goitrous tumor may become, in whole or in 
part, the seat of inflammation, and that consequently blood may be poured 
out into the cysts which it contains, or suppuration and ulceration may 
take place in it ; and that degenerative changes may ensue after a time, 
the cells within the cysts undergoing fatty disintegration, and the contents 
of the cysts consequently acquiring a milky character, or the fibroid stroma 
becoming the seat of earthy deposition — a change which is often attended 
with diminution in size and induration of the tumor. 

A bronchocele varies in consistence according to the nature of the pro- 
cesses which have been going on in it ; so that in some cases it is hard and 
resisting, in others it is soft and yielding or elastic, and in others, again, 
presents in certain situations distinct fluctuation ; and when the enlarge- 
ment of its arteries constitutes a special feature of the tumor, there may be 
pulsation resembling that of an aneurism. 

A goitre sometimes retains accurately the form of the healthy gland ; 
but more frequently it becomes unsymmetrical in the progress of its growth 
(the right lobe being especially liable to disproportionate development), and 
then by growing in certain directions, or throwing out lobules, may press 
inconveniently or dangerously on important organs in this vicinity. Occa- 
sionally small supplemental thyroid bodies may be detected in the neighbor- 



510 



DISEASES OF THE VASCULAR ORGANS. 



hood of organs thus hypertrophied ; and it is especially by the development 
of such masses at the posterior part of the lateral lobes that compression of 
the oesophagus is sometimes effected. 

The size of a goitrous tumor varies from that which produces a mere 
fulness (by some persons regarded as ornamental) in the lower part of the 
front of the neck, to a mass (usually more or less irregular in form) as 
large as a cocoa-nut, or in rare cases of such enormous dimensions that it 
hangs pendulous from the neck, concealing the chest, and abdomen, or 
even extending to the middle of the thigh. 

Symptoms and progress. — A goitre may generally be readily recognized 
by its relations with the various structures occupying the lower and ante- 
rior part of the neck, and especially by its situation in front of the trachea, 
and by its following the movements of that tube. Its development is 
seldom attended with pain, and not usually with uneasiness ; nevertheless 
various injurious consequences are apt to ensue. In the first place 'the 
tumor may prove seriously inconvenient by its mere bulk and weight. 
In the second place, it may exert pressure on the large veins in its neigh- 
borhood, or on the trunk of the sympathetic nerve, or on the pneumogas- 
tric or recurrent laryngeal, or on the brachial plexus. And in the third 
place it may displace and compress the oesophagus or trachea. Pressure 
on the oesophagus is induced mainly by enlargement of the posterior parts 
of the lateral lobes, or of the supplemental bodies occasionally found in 
this situation. Pressure on the trachea is by far the most important of 
the consequences which goitre entails. In some instances it' acts uni- 
laterally, the trachea being displaced towards one side of the neck ; in 
some instances this tube is compressed between the two enlarged lateral 
lobes ; in some the pressure is exerted in the antero-posterior direction, 
the trachea then becoming more or less flattened against the spine. The 
effect of pressure in either of these cases is often remarkable : the impli- 
cated portion of tube being sometimes flattened, sometimes made to form 
a convex bulging, so that consequently the passage becomes on transverse 
section semilunar or concavo-convex, or (if pressure be exerted equally on 
opposite sides) a rectilinear or biconcave chink, and sometimes actually 
obliterated. A slight amount of compression is not unfrequent, the patient 
breathing naturally when quiet, but with some degree of stridor and diffi- 
culty under exertion or excitement, and yet not with sufficiently pro- 
nounced difficulty to excite alarm in himself or others. In all such cases, 
however, there is danger of the supervention of fatal obstruction. In some 
this takes place gradually from the slow encroachment of the tumor ; but 
in many it comes on more or less suddenly either from the rapid develop- 
ment of some cyst, or from inflammatory tumefaction, or from congestion 
and oedema of the mucous membrane of the already compressed trachea. 
The danger of suffocation depends less on the size of the goitre than on its 
form and situation ; the most serious cases, indeed, are : first those of sub- 
sternal goitre, in which the lower portion of the gland, or some process of 
it, sinks, in the course of its enlargement, behind the sternum, and com- 
presses the trachea there, while there is yet little obvious sign of thyroid 
gland enlargement ; and, second, those of submaxillary goitre (a con- 
genital defect described by Virchow) in which the gland is situated at a 
higher level than natural, and the lateral lobes extend backwards behind 
the angles of the jaws, and sometimes as far as the mastoid processes. The 
contraction of the sterno-thyroid muscles may materially aggravate the 
compression of the deep-seated organs. To the list of dangers just enu- 



GOITRE. 



511 



meraied may be added that due to the rupture of cysts or abscesses either 
externally or into the trachea or oesophagus. 

Treatment In the treatment of goitre we have to consider : first, the 

medicinal and other means by which the tumor may be either reduced in 
size or prevented from increasing ; and, second, the measures which may 
be requisite to obviate the effects of its pressure upon important parts. 
Whenever a goitrous patient lives in a goitrous district the obvious remedy 
is his removal to some more salubrious locality ; or, if this be impossible, a 
careful investigation of the available drinking water of the neighborhood, 
and the selection for use of that which is least contaminated with earthy 
salts, or the adoption of measures, such as boiling, distillation, or Clark's 
process, for the precipitation of these ingredients previous to use. Such 
measures, and especially emigration, are often efficacious in the complete 
removal of goitrous tumors which are of small size, or have been but a 
short time in existence, and are generally beneficial even in advanced 
cases. Burnt sponge was formerly largely employed, and with reputed 
benefit, in the treatment of goitre ; but Dr. Coindet, of Geneva, after the 
discovery of iodine in sea-water and marine productions, was led to sus- 
pect that the efficacy of the burnt sponge was due to the iodine which it 
contained, and to make trial of iodine itself as an anti-goitrous remedy. 
Since that time iodine and its various preparations have replaced almost 
all other internal remedial agents and have enjoyed a singular reputation 
as specifics against this disease. The testimony, indeed, in favor of the 
curative influence of iodine is almost overwhelming. On the other hand, 
it must be remarked : that, altogether apart from the influence of iodine, 
goitre is liable to considerable fluctuations of size, and when small and 
recent often disappears entirely ; that there is little or no evidence that 
the drug is efficacious in the treatment of exophthalmic goitre, which is 
structurally identical with the endemic form of the disease ; that notwith- 
standing the supposed curative action of iodine, there is no proof that 
goitre is now less prevalent or less severe in goitrous localities than it for- 
merly was ; and that, mixed up with the evidence in favor of the specific 
virtues of iodine, is evidence equally striking in regard to the produc- 
tion of a remarkable concurrence of symptoms known by the name of 
iodism, which now seems never to attend the use of iodine, however largely 
it is administered. We must confess that, in our own limited experience 
of the treatment of goitre, iodine has signally failed. But we need not 
limit ourselves to the employment of internal remedies. By many persons 
counter-irritants applied to the surface of the tumor are strongly advocated. 
Among such applications may be enumerated iodine paint and other iodic 
preparations, strong mercurial ointment, and blisters or other forms of 
blistering agents. In some cases (generally, however, when the tumor has 
been of large size or has given indications of compressing vital organs), 
operative measures have been resorted to. The tumor has been excised — 
an operation of no inconsiderable difficulty and danger, owing to the rela- 
tions of the thyroid body and its enormous vascular supply; it has been 
treated by passing a seton through its substance and so exciting and main- 
taining inflammation or suppuration in it ; and, again, one or more of the 
arteries supplying it have been tied. Each of these operations has proved 
more or less successful in certain cases ; but none of them sufficiently suc- 
cessful on the whole to encourage its frequent performance. It must be 
observed, however, that cysts of the thyroid body admit in most cases of 
ready and successful treatment, either by simple puncture with the dis- 



512 



DISEASES OF THE VASCULAR ORGANS. 



charge of their contents, or by puncture and injection of some stimulating 
fluid, or by the employment of the seton. 

When goitrous tumors are threatening to obstruct the trachea, we must 
be alive to the possibility of the supervention at any moment of sudden 
and fatal asphyxia. What can be done under these circumstances ? Un- 
fortunately very little. If the enlargement be mainly cystic, relief no 
doubt can be afforded by the puncture of the cyst and the discharge of its 
contents. If, however, it be solid, as in the main it commonly is, it is 
difficult to see what other resource than tracheotomy is left us ; and tra- 
cheotomy in these cases is both difficult and unsatisfactory ; for it can 
rarely be performed below the seat of obstruction ; it is a formidable ope- 
ration if effected through the substance of the enlarged gland; and if done 
above the gland it is necessarily useless unless it be completed by the pas- 
sage of a sufficiently long tube through and beyond the constricted portion 
of the trachea. 

B. Cretinism. 

Cretins are persons in whom feebleness of intellect or idiocy is combined 
with certain peculiarities of bodily conformation. They are for the most 
part stunted in growth, with tumid bellies and coarse skins. In a large 
proportion of cases they are more or less obviously goitrous, though occa- 
sionally the goitre is of the latent or submaxillary kind, to which reference 
has already been made. The head is usually large and misshapen — ex- 
panded at the sides and flattened at the top ; the cheek-bones high and 
prominent ; the nose flattened or sunken at the bridge, broad at the root, 
and upturned ; the interval between the eyes increased ; the lips thick ; 
the mouth wide and open ; and the tongue large. There is generally more 
or less muscular weakness, deficiency of cutaneous sensibility, and impair- 
ment or annulment of the sexual functions ; and not unfrequently deaf- 
mutism is conjoined with the other corporeal defects. The degree of 
mental impairment varies between complete dementia and mere dulness or 
slowness of intelligence. Cretins are usually quiet and harmless, not given 
to mischief, but liable to occasional outbursts of ungovernable violence. 

True cretinism appears, according to Virchow's researches, to originate 
during foetal life in an unnatural tendency which the basilar portion of the 
occipital bone, and the post-sphenoidal and prae-sphenoidal bones, have to 
coalesce with one another by ossification of the disks of cartilage by which 
they should at that time be separated. The consequences are : that the 
base of the skull ceases prematurely to elongate, and thus becomes modi- 
fied in form ; and that this arrest of development leads, on the one hand, 
to defective development of the corresponding portion of the brain, and, 
on the other, to wide-spread changes in the osseous framework of the skull 
and face. The form of the skull gets modified, partly by the need which 
its contraction in one direction involves of compensatory expansion on the 
part of those regions whose bones have not yet coalesced, and partly by the 
opposing tendency which also exists in those cases to precocious union of 
the bones of the cranial vault along the lines of suture. The peculiar form 
which the face assumes is due in some measure to imperfect development 
of the nasal septum, in some measure to displacement of the cheek-bones 
and bones of the orbits. Further, in many of these cases the cranial bones 
acquire remarkable thickness, and the foramina at the base of the skull 
become much diminished in size. The same tendency which is presented 



CRETINISM. 



513 



by the cranial bones is presented by those of the extremities, which soon 
unite with their epiphyses. And, indeed, it is probably due, in part at 
least, to this cause that these bones remain incompletely developed. 

According to the above account of the pathology of cretinism, this con- 
dition must be regarded as of congenital origin. Children are born cre- 
tins ; that is, they are born, either with the peculiar features of cretinism 
more or less obviously developed, or with that coalescence of the bones at 
the base of the skull which necessitates the gradual development of cre- 
tinism during the period of childhood. 

Like goitre, cretinism may occur either sporadically or endemically. 
The causes of sporadic cretinism and those of sporadic goitre are alike 
obscure. Endemic cretinism, however, and endemic goitre are always 
associated, and obviously originate in a common cause. Wherever goitre 
prevails largely there cretinism is also prevalent ; the goitrous tendency, 
however, occupies a wider area, and goitrous persons always largely out- 
number their idiotic compatriots. It would seem, indeed, that for the 
production of cretinism some special intensity of the poison which also 
causes goitre is requisite. Cretins are not only in large proportion goitrous, 
but also in large proportion the offspring of goitrous parents. Yet there 
is no sufficient reason to believe that cretinism, any more than goitre or 
ague, is hereditary; for goitrous parents do not beget cretinous children 
when once they have removed from those regions in which these affections 
prevail, and under similar circumstances the children of cretins are them- 
selves free from both goitre and taint of cretinism. It seems clear, indeed, 
that the morbific matter which, taken into the mother's system, renders 
her goitrous, acts also on her foetus, causing in it, may be, not only goitre, 
but also those special developmental changes which ultimately lead to mal- 
formation and mental deficiency. In reference to the association in cre- 
tinous infants of arrested development of the base of the skull and goitre, 
it is interesting to bear in mind the fact, pointed out by Virchow, of the 
close proximity in the foetus of the base of the skull to the thyroid body. 
Assuming the common cause of goitre and cretinism to be, or to have some 
close relation with, the existence of a superabundance of earthy salts in 
drinking water, it is natural to speculate on the influence which these salts 
may have in causing the too early completion of the process of ossification. 

We have referred to the great obscurity which involves the causation of 
both sporadic goitre and sporadic cretinism. There is no evidence that 
the subjects of sporadic goitre ever beget either goitrous or cretinous chil- 
dren, or that sporadic cretins are ever the offspring of goitrous or imbecile 
parents. At the same time sporadic cretins seem always to present some 
abnormal condition of the thyroid body. In some recorded cases such 
cretins have been distinctly goitrous ; but in a large proportion of them 
there is an apparent absence of the thyroid body. In Dr. Fagge's 1 
cases, and in two previously recorded by Mr. Curling, there were soft 
elastic lumps occupying the angles between the sterno-mastoids and clavi- 
cles, which lumps, in Mr. Curling's cases, were found post mortem to con- 
sist of fat only. It may, however, be questioned whether these are not to 
be regarded as examples of that latent form of bronchocele which Virchow 
speaks of, and to which attention has already been directed. These facts 
evidently ally the cases of sporadic cretinism to those of the endemic form 
of the malady, and suggest the dependence of both on a common cause ; 



33 



1 'Med. Chi. Trans.' vol. liv. 



514 



DISEASES OF THE VASCULAR ORGANS. 



the poison (if it be a poison) being introduced, in the one case con- 
stantly and indifferently into the systems of a more or less extensive 
population, in the other case accidentally, so to speak, into the blood of 
casual units. 

Treatment The mental condition of cretins, like that of other idiots, 

admits in many cases of amelioration by proper training ; for which pur- 
pose a well-ordered asylum with skilled officials is essential. The improve- 
ment, far more the cure, of the structural lesions which underlie cretinism 
is, however, entirely beyond the resources of our art. The prevention of 
cretinism depends, so far as we know, neither on the prevention of mar- 
riage between those who are goitrous or in a condition of semi-cretinism, 
nor on prophylactic measures adopted with reference to the young children 
in whom its presence is obvious or merely suspected ; but solely on the 
observance by the parents of those special hygienic measures which are 
efficacious in the prevention of goitre. 



II. MYXGEDEMA. 

Definition and history. — This is a peculiar disease, hitherto recognized 
only in adult females, and characterized mainly by the general development 
of a kind of solid oedema, in connection with a tottering feeble gait, slow 
and monotonous utterance, and general slowness of thought and movement. 

It was first described by Sir W. Gull 1 as a ' cretinoid state supervening 
in adult life in women ;' and has since been investigated by Dr. Ord, 2 who 
has also had the opportunity of extending his inquiries into the morbid 
anatomy of the disease. We have examined Dr. Ord's cases and speci- 
mens, and are satisfied that myxoedema is a definite disease ; but, while 
admitting that it has some resemblance to cretinism, we are by no means 
satisfied that it has any essential connection with that disease, and we place 
it after cretinism only provisionally. 

Causation So far as is known myoxcedema occurs only in women, 

and never attacks them prior to adult age. No cause for it has yet been 
discovered. 

Symptoms and progress It begins insidiously, and only after some 

years attains its full development. At that time the condition of the 
patient is very remarkable. She is probably well-nourished and even fat. 
There is general oedema, which is more marked in the face and hands 
than elsewhere ; and the skin is for the most part dry and harsh. The 
oedematous parts do not pit on pressure. The features become thick, the 
alse nasi tumid, the lips large and pendulous, and the connective tissue 
round the eyes swollen, trauslucent, and colorless. The skin of these parts 
and of the rest of the face, though dry, is smooth, delicate-looking, and 
slightly translucent ; and although the face has generally a pale and waxy 
aspect, the lips are more or less rosy, and there is a persistent circum- 
scribed blush upon the cheeks. The hands are large, thick, and clumsy, 
and as Sir W. Gull describes them 4 spade-like' — an appearance which is 
due to the fact that the fingers are thickened, have lost their natural 

1 'Clinical Society's Transactions,' vol. vii. 

2 'Med. Chi. Trans.' for 1877-78. 



DISEASES OF THE SUPRA-RENAL CAPSULES. 



515 



markings and contour, and are pressed and flattened against one another. 
Her utterance is slow, monotonous, and thick in tone, something like that 
which characterizes tonsillitis. She speaks as if her tongue were too large 
for her mouth, and as if also there were some impediment to the free use 
of her organs of articulation. On looking into the mouth the tongue pro- 
bably appears to be actually larger than natural, and the interior of the 
cheeks and the soft palate, like the superficial parts of the body, oedematous. 
The muscles generally appear to be well-developed : but there is manifest 
feebleness, especially in the lower extremities ; she walks with a tottering 
uncertain gait, and occasionally her legs give way under her while she is 
walking, and she falls down. The patient's expression is placid and 
foolish ; and, just as she is slow and deliberate in her speech and walk, so 
she is slow and deliberate in all her movements and mental processes. It 
takes her probably twice as long to get through her work, of whatever 
kind, whether mental or bodily, as it did when she was in health ; and 
her interest in what is going on about her is manifestly diminished. Yet 
notwithstanding this slowness of thought and action, there is little or no 
actual mental incapacity — she retains her memory and understanding, and 
probably expresses herself as well as ever she did in speech and writing ; 
and there is no true paralysis of any muscle, no numbness or tingling; she 
retains the sense of touch unimpaired, and has the full use of her eyes, ears, 
and other organs of sense. Further there is not necessarily disease of any 
important internal viscus ; the heart and lungs are healthy, and the urine 
normal in quantity and quality. Nevertheless in Dr. Ord's two fatal cases, 
which had been long under observation, albuminuria supervened before 
death, and apparently caused it. The disease appears to be incurable. 

Morbid anatomy. — The chief condition discovered by Dr. Ord after 
death was general oedema of the connective tissue, including that of the 
kidneys, liver, and heart. The oedematous tissue of the skin was examined 
chemically by Drs. Ord and Charles and found to contain mucine in com- 
paratively large quantities — ordinary oedematous skin presenting mere 
traces or several hundred times less. It is from this peculiarity that the 
name of the disease has been derived. The myxoedematous condition of 
the kidney closely simulated subacute interstitial nephritis. The brain 
was healthy. It may be added that Dr. Ord believes that the thyroid 
body in these cases undergoes atrophy. 

Treatment can only be palliative. 



III. DISEASES OF THE SUPRA-RENAL CAPSULES. 

The supra-renal bodies are doubtless liable to most of the organic and 
other lesions to which other organs are liable; but there are only two such 
lesions of them which have any clinical interest, namely, tubercle (Addi- 
son's disease) and malignant disease. 

A. Addison's disease. {Melasma Addisonii.) 

Definition. — Tubercular infiltration of the supra-renal bodies, together 
with the remarkable group of symptoms which seem always to be asso- 
ciated with this lesion, constitutes the malady to which the name of 4 Ad- 



516 



DISEASES OF THE VASCULAR ORGANS. 



dison's disease' is now universally applied. When present in its typical 
completeness it comprises, in association, tubercular destruction of the 
supra- renal bodies, general pigmentary deposition in the rete mucosum, 
and a remarkable form of progressive asthenia which sooner or later ends 
in death. 

Causation Addison's disease occurs much more frequently in males 

than in females, and is rarely if ever met with under ten or over fifty. 
Its first symptoms have often been attributed to local injury ; and it is cer- 
tain that it occasionally appears to supervene on caries of the neighboring 
vertebrae. 

Morbid anatomy and pathology — Miliary tubercles appear in the supra- 
renal bodies, as in other organs, and by their increase in number and size, 
their coalescence, and the degenerative changes which ensue, lead after a 
while to their more or less complete destruction. In fatal cases of this dis- 
ease, the disorganization of both glands is usually complete. They may be 
diminished in size ; but are usually enlarged, forming nodulated, rounded, 
or irregular masses which are adherent to surrounding structures by cica- 
tricial tissue. On section they are found to consist of dense, grayish, 
translucent, fibroid material, in the substance of which opaque, yellow, 
cheesy nodules of various sizes are imbedded in greater or less abundance. 
In some cases these have undergone earthy infiltration, in some have soft- 
ened into tubercular abscesses. There are no lesions of internal organs or 
tissues which are constantly associated with the supra-renal affection. In 
a large proportion of cases there is absolutely no trace of any such compli- 
cation ; in about half the total number (or rather less) miliary tubercles 
have been met with in the lungs, peritoneum, mesenteric glands, and 
other parts: and in a small, but yet significant, proportion of them caries 
of the vertebrae has been present. The condition of the skin has a close 
resemblance to that of a mulatto ; it is variously described as yellowish- 
brown, dark-brown, greenish-brown, or bronze-like. This discoloration, 
which is more or less general, affects especially those parts of the body 
which are most exposed, and those which are normally the seat of pigment. 
Thus, while it tints the face, neck, and hands on the whole more intensely 
than the chest, belly, and legs, it is usually especially dark in the axilla?, 
areolae of the nipples, umbilical region, external genital organs and groins. 
The extensor aspects of the joints are generally more deeply tinged than 
the flexor, and the knuckles, therefore, and backs of the hands are darker 
than the palmar surfaces. The discoloration never presents an abrupt 
margin, but is occasionally spotty, especially on the face and neck ; and it 
is for the most part especially deep upon surfaces which have been blis- 
tered or superficially destroyed. Deep cicatrices, on the other hand, tend 
to remain pallid. Similar brown discolorations may generally be observed 
along the lines of junction of the lips, and spots and patches of the same 
kind may often be discovered on the mucous surface of the cheeks, gums, 
and tongue. The change of color is due, as is that of common freckles, or 
of the negro's skin, to the accumulation of molecular pigment in the cells 
of the rete mucosum. The hair is said occasionally to share in the general 
pigmentation. 

The relation which exists between the tubercular disease of the supra- 
renal capsules, the discoloration of the skin, and the remarkable group of 
symptoms which attend these lesions, is as yet a matter of impenetrable 
obscurity. It has been suggested that the explanation of the phenomenon 



ADDISON S DISEASE. 



517 



lies in the intimate connection which exists between these bodies and the 
great sympathetic in the abdomen. It has also been suggested that the 
supra-renal bodies, like other ductless glands, exert some important in- 
fluence over the condition of the blood, and that it is in the abolition of 
this influence that the source of the special symptoms of the disease is to 
be sought. But these are, at all events at present, mere barren specula- 
tions. It has never been shown that disease of the abdominal sympathetic 
induces symptoms resembling those of supra-renal disease ; nor that the 
blood or the excretions in Addison's disease present any constant departure 
from the healthy state. It seems probable, however, that the morbid con- 
dition of the supra-renal bodies is directly or indirectly the cause of all 
the other phenomena of the disease. 

Symptoms and progress The chief symptomatic phenomenon of Addi- 
son's disease is the gradual development of extreme debility, without 
commensurate, it may be without appreciable, loss of flesh. The patient 
observes : that he is less capable than he formerly was of sustained mus- 
cular exertion and less disposed for it; that he cannot walk far without 
suffering from shortness of breath and palpitation ; and that if he persist 
in his efforts he falls into a state of prostration, which may continue on him 
for many hours or for days. Together with these symptoms he suffers from 
general lassitude and chilliness, and frequent sighing and yawning; he 
probably loses his appetite, and has occasional attacks of nausea and vomit- 
ing. He perhaps also complains of pains across the loins or sacrum, or in 
the epigastrium and hypochondriac regions. There may possibly be some 
giddiness and dimness of vision. The heart's action becomes extremely 
feeble, its sounds perhaps scarcely audible, and the pulse at the wrist small, 
weak, and sometimes imperceptible. As to rate, it may be normal, or 
quickened, but is often below the average. In the great majority of cases 
some obvious darkening of the skin goes along with the above symptoms; 
sometimes it precedes them in point of time, sometimes follows them, some- 
times makes its appearance concurrently with them. It is often first ob- 
served by the patient's friends, who probably think that jaundice is coming 
on, or accuse him of want of cleanliness ; but before long it gets quite 
obvious to the patient himself as well as to those about him. It is first 
recognized in the face, neck, and hands ; and generally manifests itself on 
the upper half of the body earlier than on the lower half. The tint gradu- 
ally increases in intensity, especially in those situations which usually 
tend to get darkest ; but the degree which it ultimately attains differs 
greatly in different cases. In some, though obvious, it is slight up to the 
close of life; in others the skin acquires the depth of hue of that of a 
mulatto or negro. In a small proportion of cases no change of color what- 
ever ever takes place. The conjunctivae in all cases maintain their normal 
pearly lustre throughout. The phenomena above detailed are associated 
with many negative features of significant importance. The skin remains 
cool, pliable, and normal in texture ; there is no rise of temperature ; the 
tongue is clean and moist ; and, beyond nausea and sickness, there are no 
indications whatever of inflammation or organic disease of the chylo-poietic 
viscera ; the bowels are regular ; and the urine is scanty but normal in 
appearance and constitution, excepting that urea is for the most part largely 
reduced in quantity. 

With the progress of the case the debility increases. This is not always 
obvious as the patient lies quiet in bed (to which he is probably before long 
confined), but especially manifests itself in the supervention of alarming 



518 



DISEASES OF THE VASCULAR ORGANS. 



prostration after any unwonted effort. The nausea and sickness increase, 
but are liable to variation, and may even disappear for a while ; they are 
not unfrequently associated with good appetite. The patient suffers occa- 
sionally from headache in addition to his other pains, and complains at 
times of chilliness — his hands, feet, and nose probably becoming cold and 
livid from imperfect circulation ; the temperature in the axilla not unfre- 
quently falls a degree or more ; sometimes, on the other hand, it rises one, 
two, or three degrees ; and, although no actual paralysis may be present, 
he is apt to complain of numbness in his lower extremities and to believe 
that he has lost the use of them. Towards the close of the disease the 
breath and skin often yield an offensive cadaveric odor ; the skin occasion- 
ally becomes furfuraceous ; the patient grows apathetic, and disinclined 
to make any unnecessary movement, or even to reply to questions ; and, 
although now and then becoming delirious, usually remains conscious to 
the last. Death results from asthenia, and is sometimes brought on by a 
sudden attack of faintness, which may be referable to some apparently 
trivial exertion. 

It has been assumed in the foregoing account that the patient is free 
from tubercle of other organs or from vertebral caries. The presence of 
such complications tends more or less to mask the phenomena due to the 
supra-renal disease. It is important, however, to note that, even in com- 
plicated cases, the complications are rarely so extensive or serious as of 
themselves to cause death, or so engrossing by the phenomena to which 
they give rise as materially to obscure the diagnosis of the supra-renal 
lesion. It might, indeed, almost be said that the presence of tubercles in 
the lungs and elsewhere, or of caries of the spine, should bring with it a 
thought as to the possible presence of supra-renal complication. 

There is unfortunately no reason to doubt that Addison's disease is always 
ultimately fatal. The duration of the malady is, however, subject to con- 
siderable variation. It is probably not possible in any case to ascertain 
the exact date of the commencement of the disease ; there are good reasons, 
indeed, for believing that the process of supra-renal degeneration is always 
far advanced before the clinical signs of the affection reveal themselves. 
Counting, then, from this latter date, the malady is sometimes remarkably 
rapid in its progress — proving fatal in the course of two or three weeks — 
while sometimes it is prolonged for several years. More commonly it ter- 
minates fatally within a year. It is important, however, to observe : that 
the progress of patients with this disease is not always uniformly from 
bad to worse ; but that they are liable to attacks of nausea and prostra- 
tion, so severe as to threaten life, alternating with periods of greater or 
less duration in which they gain flesh, and seem to be fairly comfortable 
and hopeful ; that many subjects of it doubtless fight against advancing 
weakness, not admitting themselves to be out of health, until possibly one 
of those sudden failures of the vital power to which they are liable com- 
pels them to yield ; and, lastly, that such sudden seizures may often be 
warded off by scrupulous avoidance of mental or bodily exertion, exposure 
to the influence of cold, and errors of diet, and thus the patient's life be 
greatly prolonged. The debility induced by supra-renal disease is in this 
respect very much like that which attends saccharine diabetes. 

Treatment. — The cure of Addison's disease is beyond our power ; and 
all, therefore, that we have to do is to endeavor, by counteracting the vari- 
ous secondary phenomena of the disease, to prolong life and render it en- 
durable. It is of the utmost importance to maintain the patient at rest, as 



DISEASES OF THE SPLEEN. 



519 



regards both mind and body, and to keep him warmly clad and in an apart- 
ment of agreeable and moderate temperature. Sickness and irritability of 
the stomach should be relieved by appropriate remedies ; tonics (the nature 
of which must be determined by the condition of the patient's digestive 
organs) should be administered ; and he should be nourished and supported 
by wholesome and nutritious food, with such a proportion of alcoholic stimu- 
lants as may seem to be needed. 

B. Tumors of the Supra-renal Capsules. 

The various forms of malignant disease are all apt to attack the supra- 
renal bodies secondarily ; and in rare cases these organs are the seat of 
their primary development. When the disease is secondary, the supra- 
renal growths rarely attain a large size, and probably nothing occurs dur- 
ing the whole course of the case to direct attention to them. When, how- 
ever, the disease is primary in them, they may form tumors as large as a 
cocoanut, which, from their size and situation, may be easily recognized 
during life. It would be difficult, if not impossible, to distinguish such 
tumors from renal tumors ; they occupy, in fact, exactly those situations 
which tumors originating in the upper part of the kidneys would occupy. 
They form rounded or lobulated immovable masses, springing from the 
posterior part of the abdomen, and are usually crossed by the ascending 
or descending colon, which they push forwards in their growth. Their 
development is sometimes attended with frequent paroxysms of agonizing 
pain, and always with the emaciation, debility, cachexia, and other phe- 
nomena which are associated with the progress of visceral malignant dis- 
ease ; but never, so far as is known, with the specific symptoms of Addison's 
disease. 



IV. DISEASES OF THE SPLEEN. 
A. Congestion. 

Causation. — Congestion of the spleen is a condition of common occur- 
rence under a large number of circumstances. It habitually takes place 
during the progress of digestion. Pathologically it is mainly observed : 
first, in dependence on lesions involving mechanical impediment to the 
escape of blood from the spleen, such as obstructive cardiac and pulmonary 
affections, and especially those diseases of the liver in which the portal 
vessels are implicated ; and, second, in connection with numerous acute 
febrile disorders, of which typhus, enteric fever, pyaemia, and malarious 
affections may be taken as the types. 

Morbid anatomy In congestion the blood accumulates in the small 

vessels and intervascular blood-passages, and the organ becomes propor- 
tionately enlarged. The rapidity with which this enlargement takes place 
and subsides is quite remarkable. The congested organ may attain five or 
six times its original bulk, while retaining its normal form ; and usually 
becomes in proportion to the amount of blood which it contains, pulpy, 
lacerable, and even diffluent. When the congestion is frequently repeated, 
as in ague, or long continued, as in portal obstruction, the enlargement 
tends not only to increase, but to become permanent. 



520 



DISEASES OF THE VASCULAR ORGANS. 



Symptoms and progress — Simple congestion of the spleen rarely, if 
ever, reveals itself by symptoms, and equally rarely calls for special medi- 
cal treatment. It can, however, often be recognized during life (if sought 
for in those cases in which it is specially liable to occur) by the presence 
of a manifest tumor in the splenic region. The normal spleen is situated 
upon the cardiac extremity of the stomach, its convex surface being in 
contact with the diaphragm, and no part descending below the ribs. Its 
lowest point is then in close proximity with the anterior extremity of the 
eleventh rib, from which point upwards a limited area of dulness, due to 
its presence, may sometimes be detected on the left side of the thorax. 
The enlarged organ, 'however, while partly rising into the chest and in- 
creasing the area of splenic dulness in that situation, mainly spreads farther 
and farther into the abdominal cavity, taking a course downwards and in- 
wards. In cases of extreme enlargement it may occupy nearly the whole 
of the left half of the abdomen — extending from the ribs above to the 
inguinal region below, and from the lumbar region behind to beyond the 
umbilicus, and causing distinct protrusion of the abdominal parietes. A 
splenic tumor is usually readily movable, sinking and rising with the re- 
spiratory movements, and capable of obvious displacement under manual 
pressure; its anterior edge can generally be readily felt, and found to pre- 
sent the characteristic splenic notches. If symptoms be present they are 
mainly a sense of weight or tension in the side and more or less tenderness 
on pressure. It has occasionally happened that rupture of the greatly con- 
gested spleen has taken place ; in which case death has occurred with some 
rapidity, either from the escape of blood into the peritoneal cavity, or from 
peritonitis. 

Treatment The treatment of hyperemia consists mainly in the treat- 
ment of the morbid condition which gives rise to it. 

B. Hypertrophy. 

Causation — True hypertrophy is for the most part the consequence of 
long-continued or repeated congestion. It is therefore frequently found 
associated with cirrhosis and other chronic affections of the liver, and is a 
common consequence of repeated attacks of malarious fever. It is, more- 
over, a usual complication of rickets. But some of the most remarkable 
examples of this affection are furnished by persons who have never suffered 
from any of the above disorders, and in whom there is no history pointing 
to the operation of any specific cause. 

Morbid anatomy — In true hypertrophy, the organ enlarges without 
undergoing any obvious change in texture ; there is a general increase of 
all its elements in pretty nearly equal proportion, and it acquires for the 
most part a more or less firm fleshy consistence. It is in this condition that 
the spleen attains its greatest volume, sometimes filling the left side of the 
abdomen, from the ribs above to the pelvis below, and from the lumbar 
region behind to some inch or two, or more, beyond the umbilicus. It may 
then measure as much as sixteen inches in length, ten in breadth, and five 
or six inches in thickness, and weighs ten, tw T elve, or even twenty pounds. 
It retains its normal shape. 

Symptoms and progress — The symptoms due to simple hypertrophy 
are, for the most part, very vague, and difficult to disentangle from those 
of other lesions with which they are frequently associated. Persons thus 
affected often suffer from anamria, discharges of blood (especially from the 



DISEASES OF THE SPLEEN. 



521 



gastro-intestinal mucous membrane), and abdominal dropsy; but it is un- 
certain how far these phenomena depend on the hepatic lesion which so 
commonly goes along with splenic enlargement, how far on the splenic dis- 
ease. But, putting such symptoms aside, there is nothing left to indicate 
the presence of splenic hypertrophy beyond the local phenomena to which 
it gives rise. The chief of these is the manifest existence of a tumor, 
which presents the characters (before described) of enlarged spleen, is tough 
and unyielding in consistence, gives to the patient a sense of weight and 
fulness, especially if he lie upon his right side, and is unattended with pain 
or tenderness on pressure. A venous hum, of more or less musical char- 
acter, may occasionally be recognized on the application of the stethoscope 
over the tumor. The duration of these cases is always uncertain, and often 
much prolonged. In some instances amelioration or cure takes place under 
suitable treatment ; in some the organ remains stationary, and yet with 
little manifest deterioration of the patient's health ; in many death ensues 
sooner or later, either from simple anaemia and debility, or from these con- 
ditions associated with hemorrhage, dropsy, or some other intercurrent 
affection. 

The treatment of hypertrophy must depend largely on the constitutional 
malady which has given rise to it. If it be a sequel of ague, quinine or 
arsenic is indicated ; if the patient be suffering from rickets the remedies 
suitable for that condition must be employed ; if there be heart, pulmonary, 
or renal disease, our efforts must be regulated accordingly. In many cases, 
however, no such clue is furnished ; and we must then have recourse to 
those remedies which the general condition of the patient seems to suggest ; 
among the more important of which may be enumerated iodine, iodide and 
bromide of potassium, iron, quinine, and other tonics. The bowels should 
be kept freely open — if necessary, by the use of mild laxatives. 

C. Inflammation. 

Causation Inflammation of the spleen, at least in an acute form, is 

exceedingly rare, excepting in those cases in which it is due to injury, 
embolism, pyaemia, or the presence of morbid growths or foreign bodies. 

Morbid anatomy Splenic embolism is most frequently a consequence 

of valvular disease of the heart. It leads to the formation of wedge-shaped 
blocks, or masses, which vary in size from a cubic inch or two downwards, 
are often multiple, and usually abut on the surface of the organ. In the 
first instance they are mainly hemorrhagic, and distinguishable from the 
splenic tissue by their darker color and greater solidity ; but soon the 
coloring matter gets absorbed, and the masses pass through various stages 
of reddish-brown, yellowish-brown, and buff-color, until they become al- 
most pure white. Sometimes they soften into a puriform pulp, sometimes 
undergo actual suppuration, and sometimes (especially if small) get ab- 
sorbed, leaving depressed cicatrices behind, in which earthy particles may 
remain imbedded. The presence of these infarctions generally gives rise 
to more or less inflammation in the peritoneal surface over them. 

Pyaemic formations present much the same characters ; but they are 
usually more numerous and smaller, and their tendency to soften, suppurate, 
and involve the peritoneum covering them, is much more marked. 

Splenic abscesses may result from the above and various other causes, 
and, like other abdominal abscesses, may acquire large dimensions, and 
are liable to various terminations. They may open externally through the 



522 



DISEASES OF THE VASCULAR ORGANS. 



abdominal walls, or rupture into the peritoneum, or discharge their con- 
tents into the stomach, colon, left lung, or pleura. Adhesive inflammation 
is not uncommon at the surface of the spleen, and occasionally circum- 
scribed suppuration occurs between this organ and some neighboring part, 
such as the stomach, diaphragm, colon, or abdominal walls. 

Symptoms In most of the affections now under consideration there is 

little or nothing special excepting locality to direct attention during life to 
the spleen as the seat of disease. There may be, and indeed probably al- 
ways is, manifest increase of size of the organ, together with uneasiness, 
pain, and tenderness. The pain, when severe, is mainly due to circum- 
scribed peritonitis, and, from the position and relations of the organ, is 
liable to augmentation during the respiratory movements. The recogni- 
tion of an abscess will depend on its attainment of such a size as to form 
an appreciable fluctuating tumor in the splenic region, and on the pheno- 
mena which attend and follow the process of pointing and the discharge of 
its contents. In all these cases, sympathetic vomiting and febrile symp- 
toms of more or less intensity will almost certainly manifest themselves, 
and rigors are not unlikely to supervene. But it is rare for the splenic 
affection to be so free from complication as to justify us in attributing them 
to it. 

Special treatment will only be called for when pain is complained of or 
when an abscess becomes manifest. In the former case, poultices, fomen- 
tations, and leeches are the most useful applications ; in the latter the case 
must be treated as one of hepatic or other internal abscess. 

D. Tubercle. 

Tubercles are very common, especially in young children, and in con- 
nection with tuberculosis of other organs. The spleen thus affected is 
usually somewhat enlarged and studded more or less thickly with them. 
They are frequently miliary and gray, in which case they may be readily 
mistaken for the Malpighian bodies ; usually, however, some of larger size 
may also be detected which have already undergone caseation, and thus 
furnish a clue to the nature of the others. Yellow tubercular masses, ir- 
regular in form, and varying from the size of a horse-bean to that of a tare, 
are also not unfrequently discovered, in greater or less abundance. Occa- 
sionally they soften into cavities or form abscesses. Filamentous processes 
of false membrane, themselves studded with tubercles, are often attached 
to the surface of tuberculous spleens. 

Tuberculosis of the spleen can scarcely be recognized during life. If 
symptoms attend it, they will be such as to suggest either congestion, ab- 
scess, hypertrophy, or some other than tubercular lesion. 

E. Tumors. 

The various forms of malignant disease affect the spleen with different 
degrees of frequency and in different modes. First, the peritoneal aspect, 
or the connective tissue about the hilum, may get involved by continuity, 
in the course of malignant disease of the peritoneum, stomach, or glands 
in the neighborhood of the stomach ; and then the morbid growth either 
invades the organ from different parts of its surface, or runs into its sub- 
stance along the vessels which enter at the hilum. Second, the spleen 
may have isolated secondary growths developed here and there in its sub- 



DISEASES OF THE SPLEEN. 



523 



stance. Or, third, it may be the seat of the primary manifestation of the 
disease. The last alternative, however, is rare. 

Most of the different forms of malignant disease fail to cause any great 
enlargement of the spleen, or to indicate their presence by special symp- 
toms ; and consequently the splenic affection is usually overlooked during 
life. Still such growths may attain considerable size in that organ, and 
convert it into an irregular and more or less indurated mass, readily recog- 
nizable during life by palpation, and even (in connection with other phe- 
nomena) as a malignant growth of splenic origin. It must not be forgotten, 
however, that tumors of the great omentum, or other parts of the perito- 
neum in the neighborhood of the spleen, are very apt to simulate splenic 
tumors and to be mistaken for them. These remarks do not apply to 
lymphadenoma. In this, as in simple hypertrophy, the spleen undergoes 
a nearly uniform enlargement ; sometimes acquiring gigantic proportions, 
but still retaining its natural form, and the characteristic features by which 
an enlarged spleen may usually be recognized. 

The symptoms of splenic malignant disease are not usually of much in- 
terest or importance. Those which attend lymphadenoma of the spleen 
will be most conveniently discussed hereafter in connection with those due 
to the same affection of the lymphatic glands. 

F. Cysts and Hydatids. 

Simple serous cysts are rare in the spleen, and, so far as we know, un- 
important. They are occasionally multiple, and associated with the 
development of numerous similar cysts in the liver and kidneys. 

Hydatids are more common and far more important. But their course 
and the symptoms to which they give rise are identical (excepting in one 
or two obvious particulars) with those of hydatids of the liver or perito- 
neum, and need not be particularly considered now. 

G. Atrophy. 

Atrophy is exceedingly common, and traceable to various causes. In 
some cases it appears, like cirrhosis of the liver, to be consequent on an 
interstitial overgrowth of connective tissue ; in some, as also occurs in the 
liver, to the investment of the organ in a dense and slowly contracting 
fibrous capsule. But, however produced, it is a lesion which, so far as we 
know, causes little or no inconvenience and no symptoms by which its 
existence may be diagnosed. 

H. Lardaceous Degeneration. 

Morbid anatomy. — The spleen is perhaps more frequently the seat of 
the lardaceous change than any other part of the body ; but it is generally 
thus affected in association with one or more of the several other organs 
which are liable to the same change. Lardaceous degeneration first affects 
the minute arterial twigs and the cells external to them with which they 
are in relation. It is especially apt to commence in the Malpighian bodies 
and vessels which are connected with them. The lardaceous spleen under- 
goes gradual and uniform enlargement, and may attain dimensions nearly 
as extreme as those reached by the simply hypertrophied organ. Its cap- 
sule is usually smooth and glistening ; and on section the organ presents 



524 



DISEASES OP THE VASCULAR ORGANS. 



different appearances according to the degree to which the degeneration 
has advanced. In the earlier stages it exhibits those characters which 
have gained for it the name of the ' sago' spleen. It is thickly studded 
with grayish translucent rounded masses, which have a close resemblance 
to boiled sago-grains, and which are separated from one another by a net- 
work of still healthy tissue. In the later stages these rounded bodies have 
coalesced, and the spleen is involved uniformly in its whole extent. In 
this condition the spleen presents on section a nearly uniform grayish, 
translucent, glistening aspect, yields little or no fluid on pressure, and 
takes the impress of the finger like a piece of wax or stiff dough. It is 
abnormally heavy, and readily lacerable — breaking however with a some- 
what vitreous fracture. 

Symptoms. — Lardaceous spleen is always associated with more or less 
anaemia or cachexia, and often with dropsy, tendency to hemorrhage, and 
other symptoms, for the most part indicative of debility. It is never 
possible, however, to decide to what extent these various symptoms depend 
on the splenic disease — which is always secondary to grave chronic lesion 
of other organs, and generally associated with similar degenerative changes 
elsewhere ; to what extent they are referable to these several antecedent 
or concurrent affections. 

Treatment Lardaceous spleen probably never calls for independent 

treatment. Our first efforts must be directed to the cure of the lesion out 
of which the tendency to lardaceous change has arisen ; our next to the 
improvement of the patient's general health by the exhibition of iron and 
other tonics, the administration of abundant nutritious food, and attention 
to all those hygienic measures which are generally beneficial in cachectic 
conditions. 



V. DISEASES OF THE LYMPHATICS. 

There are probably no organs or tissues of the body the pathological 
relations of which are more important than those of the lymphatic vessels 
and glands ; no organs which are more frequently involved in the course of 
diseases originating in other parts ; none, the proper diseases of which 
more profoundly affect the general organism. Their affections are, for the 
most part, however, so intimately connected with those of other organs, or 
with so-called ' general ' diseases, that the discussion of the latter neces- 
sarily involves that of their lymphatic complications. It is needless, there- 
fore, notwithstanding its surpassing interest and importance, to enter at 
any length upon the subject of the diseases of the lymphatic system. 

A. Inflammation. 

Causation Inflammation of the lymphatics is, no doubt, sometimes 

primary, in the sense in which idiopathic pneumonia is primary, and 
sometimes the consequence of blows or other forms of direct mechanical 
violence ; in the great majority of cases, however, it arises secondarily to 
some local inflammation, or is the consequence of some irritant acting 
through the blood. 

Morbid anatomy. — If the glands be secondarily affected, those only 
suffer which lie next above the inflamed area, in the line of the lymphatic 



DISEASES OF THE LYMPHATICS. 



525 



vessels. In this case irritating matters, probably the products of inflam- 
mation, are taken up by the lymphatics, and conveyed along them until 
they get arrested in their progress by the glands. During the passage of 
these matters the vessels sometimes inflame, their parietes get thickened 
and vascular, and the connective tissue around them congested and infil- 
trated ; and thus their course becomes indicated by red tumid bands. 
Sometimes, indeed, abscesses form along them. On the other hand, lym- 
phatic vessels frequently convey, without injury to themselves, matters 
which excite violent inflammation in the glands, and ulterior mischief of 
the gravest character. Inflammation of the lymphatic glands is marked 
by hyperemia, succulence, softening, and swelling, and an excessive 
development of cells resembling those natural to the healthy organs. Sup- 
puration sometimes ensues, and occasionally (especially among lax tissues 
such as that of the axilla) enormous abscesses result. In some instances 
the inflammation assumes a chronic character, and ends in the induration, 
contraction, and atrophy of the glands. The nature of the inflammation, 
and its tendency in respect of result, differ in accordance with the charac- 
ters of the local inflammation, and of the specific disorder to which it owes 
its origin. 

Symptoms and progress. — The symptoms due to lymphatic inflamma- 
tion are principally swelling, heat, pain, and tenderness in the course of 
the affected vessels and in the affected glands, with visible hyperemia in the 
situation of such as occupy a superficial position, and febrile symptoms of 
more or less severity. Indeed the fever is generally severe — apparently 
out of all proportion to the extent and importance of the inflamed tract — 
and not unfrequently attended with rigors. Its severity is doubtless due 
in no small degree to the fact that the inflamed lymphatics are in direct 
communication with the blood, and are constantly pouring the products of 
their inflammation into it. 

Treatment — For the general treatment of inflamed glands (supposing 
them to need any apart from the affection to which their inflammation is 
secondary) no rules need be laid down beyond such as should guide us in 
the treatment of tonsillitis and other such disorders. For local treatment, 
leeches, fomentations, poultices, and in some cases cold applications, are 
chiefly important. When the inflammation is chronic, counter-irritants, 
iodine paint, strong mercurial ointment, and blisters will probably be more 
efficacious. 

B. Tubercle. Scrofula. 

Morbid anatomy It is not easy to draw a distinct line between tubercle 

of the lymphatic glands and that enlargement of them which so commonly 
occurs in so-called ' scrofulous' children. 

But however different these affections may appear to be from one another 
in their early stages, it is certain that in both there is an equal tendency 
for the affected glands to undergo speedy caseous degeneration, and to be 
converted into opaque yellowish, friable, fattily-degenerated masses, which, 
according to their situation and other attendant circumstances, either 
soften or suppurate, or become converted into encysted mortary or creta- 
ceous masses. Softening with ulcerative destruction takes place especially 
in connection with mucous surfaces; softening with formation of abscesses, 
in the case of the glands which are superficially placed; cretaceous changes, 



526 



DISEASES OF THE VASCULAR ORGANS. 



in the glands of the mediastinum and mesentery, and others which lie deep 
in the interior of the body. 

Symptoms and progress — The symptoms of tubercular or scrofulous 
disease of the glands are rarely characteristic except when the affected 
glands are so situated as to admit of ready examination. They are then 
as a rule scarcely painful or even tender, and are usually indolent in their 
progress ; suppuration is long delayed and slow to reach the surface ; and 
even after the contents have been evacuated the abscess continues to dis- 
charge for an indefinite time ; and when at length the cavity heals, the 
scar which remains is ragged and unsightly. The general symptoms are 
those of debility and constitutional weakness. 

Treatment The general treatment of scrofulous disease of the glands 

consists in the use of tonics, cod-liver oil, and good, nourishing diet, change 
of air, and generally careful attention to hygienic measures. The local 
treatment belongs mainly to the surgeon. So long as the glands are 
neither painful nor suppurating, it is probably best to trust wholly to con- 
stitutional treatment ; but when pain or suppuration arises, poultices or 
fomentations are demanded, and, in the latter case, sooner or later the 
surgeon's knife. 

C. Morbid Growths. 

Morbid anatomy — Malignant disease, commencing elsewhere, invari- 
ably soon attacks the lymphatics, and in the first instance those glands 
which lie nearest to the primary spot of disease, between it and the tho- 
racic duct. These glands, indeed, generally become rapidly and exten- 
sively involved, forming large tumors, which sooner or later coalesce with 
one another, and implicate in the progress of their growth the surrounding 
tissues. Thus, in malignant disease of the tongue or mouth, the glands 
at the angle of the jaw first suffer ; when the breast is the source of infec- 
tion, the axillary glands ; when the lungs, the bronchial glands ; when the 
stomach or bowels, the mesenteric or retro-peritoneal glands ; when the 
penis, the glands of the groin ; when the testicle, those lying in the lumbar 
region. In some cases involvement of the lymphatics forms a still more 
obvious factor of the disease ; and it may be primary. The most remarkable 
example of this kind is furnished by lymphadenoma, which (as has been 
before pointed out) affects primarily not only the lymphatic glands but 
the lymphatic tissues throughout the system, and though not necessarily 
limited to these in its ulterior development, commits its ravages mainly 
upon them. 

Symptoms and progress The constitutional symptoms caused by malig- 
nant disease of the lymphatics are mainly those of malignant disease gener- 
ally ; when, however, these organs are implicated, the morbid process has 
already begun to exert a specific influence over the system, and the so- 
called ' cancerous cachexia,' if not previously manifest, becomes, for the 
most part, rapidly developed. The local symptoms are those of a more or 
less painful rapidly growing tumor, the direct results of which depend upon 
its situation. 

Treatment Palliative measures only are, as a rule, available in malig- 
nant disease of the lymphatic glands. Accessible glands occasionally admit 
of removal with temporary benefit. 



DISEASES OF THE LYMPHATICS. 



527 



D. Mediastinal Tumors. 

Morbid anatomy Malignant tumors are of common occurrence in the 

mediastina, and are often primary in this situation. It is not always easy 
to determine in what tissue they have originated. It is certain, however, 
that they often appear to start from the lymphatic glands in the posterior 
mediastinum, and from that part of the anterior mediastinum in which are 
situated the remains of the thymus gland. It is not improbable that they 
arise also in the substance of the connective tissue. The nature of the 
disease varies in different cases ; sometimes it is cancer, but probably much 
more frequently sarcoma or lymphadenoma. The growth gradually in- 
creases in bulk, and, even if it did not originate in the lymphatic glands, 
very soon involves them, and gradually implicates all the surrounding 
parts. Thus, it may invade all the tissues of the anterior and posterior 
mediastina, surrounding and involving the fibrous pericardium and the 
adjoining parts of the parietal pleurae ; or it may involve the roots of the 
lungs, extending along the bronchial tubes and vessels into the substance 
of the lungs, or implicating the neighboring parts of these organs by con- 
tinuity, and probably constituting large tumors in them ; or it may extend 
into the cardiac walls, either infiltrating their substance or forming distinct 
growths. Further, it is apt, sooner or later, to implicate the trachea, bronchi, 
or oesophagus, the innominate veins or cava, or the recurrent laryngeal 
nerves ; or to involve the lymphatic glands above. one or other clavicle ; or 
to lead to the development of tumors in the ribs or soft tissues of the tho- 
racic walls. The dimensions which mediastinal tumors attain are some- 
times enormous; they may become as large as an orange, cocoanut, or 
child's head ; moreover, in their grow T th they tend to cause much compres- 
sion and displacement of parts. The heart, for example, may be carried 
into the left axilla, or even into the right. 

Symptoms and progress The symptoms to which mediastinal tumors 

may give rise are necessarily very various, and depend mainly on their 
seat and bulk and the particular intrathoracic organs which they impli- 
cate. They are almost identical, indeed, with those caused by intrathoracic 
aneurisms. The early symptoms are vague, but not unfrequently include 
more or less progressive anaemia, debility, and shortness of breath. The 
more characteristic phenomena slowly supervene — the order of their se- 
quence varying, however, in different cases. Sometimes the veins get 
obstructed ; those of one-half of the head and neck and face and of the cor- 
responding shoulder, arm, and side of the chest, or those of both sides 
equally, become dilated, tortuous, and full; and the implicated regions 
acquire a ghastly, livid, or congested aspect, and get more or less puffy or 
cedematous. This limited congestion and oedema are very striking phe- 
nomena ; especially when, as generally happens, the rest of the body is 
getting pallid and wasted. Sometimes the respiratory organs suffer, and 
the patient has difficulty of breathing, with cough, and probably expecto- 
ration. The symptoms then are either like those of slowly advancing 
bronchitis ; or, owing to implication of the trachea or recurrent laryngeal 
nerves, like those of laryngeal disease, and attended with hoarseness or 
aphonia, and attacks of suffocative cough ; or, in consequence of the form- 
ation of tumors in the lungs or of the supervention of pneumonia or pleu- 
risy, like those ascribed to these several affections. Sometimes the symp- 
toms are mainly cardiac, and simulate those due to valvular disease. 
Sometimes the patient has difficulty or pain in swallowing. And often, 



528 



DISEASES OF THE VASCULAR ORGANS. 



in connection with cardiac, pulmonary, or laryngeal symptoms, or those 
of venous obstruction, he complains of vertigo, headache, and even of 
occasional attacks of momentary unconsciousness or slight convulsion. 
It is not uncommon to have blood in the expectoration ; and late in the 
disease the sputa are apt to be abundant, muco-purulent, and fetid. 

The diagnosis of mediastinal tumors is often largely aided by physical 
examination ; by the gradual extension of the area of precordial dulness, 
by the increase of resistance experienced on percussion, by the displace- 
ment of the heart or lungs, or by the supervention of pulmonary consoli- 
dation or pleural effusion, and the modification in the auscultatory pheno- 
mena which these several affections entail. It is further aided by the 
presence of localized dilatation of veins in the thoracic parietes. But the 
most important indications are those furnished by the development of tu- 
mors in the thoracic parietes or above the clavicles. 

It must not be forgotten that in the course of mediastinal disease second- 
ary tumors are apt to arise in other parts of the body ; and that these 
occasionally cause more striking symptoms than the primary disease, which 
may then be overlooked. Thus it is not uncommon in these cases for 
secondary tumors to develop in the brain, and for the patient to die of the 
cerebral complication. 

It is obvious that the symptoms of mediastinal growths are made up 
mainly of those due to implication of the various important organs which 
occupy the mediastina or abut upon them ; and in order that the reader 
may have a clear conception of their variety and importance, and a thor- 
ough picture of the disease, we must refer him to the descriptions else- 
where given of the phenomena referable to lesions of the several organs 
here adverted to. 

It need scarcely be added that mediastinal tumors are progressive in 
their course, and always sooner or later prove fatal. The causes of death 
are various. 

Treatment. — There are no special indications for the treatment of me- 
diastinal tumors — symptoms must be dealt with as they arise. 

E. Obstruction and Dilatation of the Lymphatic Vessels. 

Morbid anatomy and symptoms — Obstruction of the thoracic duct may 
be caused by the pressure of tumors, by disease of its walls, or by a morbid 
condition of its contents ; but is of rare occurrence. It might be supposed 
that it would lead to very rapid innutrition, and at the same time to 
general dilatation of all the lymphatics, excepting those of the right upper 
extremity and corresponding side of the head, neck, and thorax. But 
experience and experiment alike seem to show : that whilst sudden ob- 
struction usually results rather quickly in great over-distension of the lower 
part of the duct and especially of the receptaculum chyli, which presently 
ruptures with extravasation of its contents into the retroperitoneal tissue ; 
slowly induced obstruction may be compensated for by the enlargement of 
existing communications between the obstructed left and the still pervious 
right duct. 

Obstruction occurring in a group of lymphatic glands in consequence of 
disease going on in them, or in a group of lymphatic vessels as a result of 
pressure upon them or of their involvement in disease, always leads in the 
first instance to stasis and accumulation of lymph within the tributary 
vessels, which consequently dilate, and subsequently to similar accumula- 



LEUCOCYTHiEMIA. 



529 



tion within the lymphatic spaces and to their disproportionately large ex- 
pansion. The lymph-channels, indeed, and the tissues generally, become 
surcharged with lymph — a clear or milky yellowish alkaline fluid of a 
sickly odor, which contains albumen, fibrinogen, and lymph-corpuscles, 
and among other occasional constituents sugar and molecular fatty matter, 
and which, like the plasma of the blood, coagulates more or less perfectly 
on removal from the body. The result is the development of what is often 
termed solid oedema or leucophlegmasia of the implicated portion of the 
body ; which becomes swollen and tense, and of a pale waxy aspect, but 
does not pit on pressure as in ordinary venous dropsy. And, further, if 
the condition be of long duration, and especially if it originated in infancy 
when the organism was undergoing rapid growth, the tissues of the affected 
region — not only connective tissue, but muscles, bones, and skin — all be- 
come distinctly hypertrophic. Obstruction and dilatation of the lymphatics 
is the essential feature or an important factor of several well-recognized 
pathological conditions. A particular form of enlargement of tongue, 
usually congenital, in which the organ tends to grow, to protrude from the 
mouth, and to interfere by its bulk with the growth of the jaws, has been 
shown by Virchow to be due to lymphatic obstruction. The tongue is 
honey-combed with dilated lymph-channels, and the seat of consequent 
overgrowth of all the tissues of the organ inclusive of the muscular sub- 
stance and of the papillary surface. The upper extremity has occasionally 
become, from accidental circumstances, similarly affected. But the most 
frequent, and, on the whole, the most interesting example of such obstruc- 
tion and its consequences is afforded by the lower extremity and the ad- 
joining portions of the abdomen and genital organs, in the condition we 
have already described under the name of elephantiasis lymphangiectodes. 
The last morbid condition characterized by dilatation of the lymphatics to 
which we shall refer is elephantiasis Arabum, a disease which, like the 
last, is more fully discussed in another part of this volume. 

Treatme/nt It is obvious that no medicines are competent to relieve 

the various consequences of obstruction of the lymphatics ; recourse can 
only be had to mechanical or operative measures. In enlargement of the 
tongue, portions of the organ have been excised with benefit ; as also have 
portions of the prepuce when that structure has got hypertrophied. 



VI. LEUCOCYTHiEMIA. {Leuhcemia.) 

Definition — By the above term is meant a disease characterized by a 
combination of enlarged spleen, enlarged lymphatic glands, or both of these 
conditions, with an excess of white corpuscles in the blood. 

Causation. — The cause of leucocythsemia is very obscure. Dr. Gowers 1 
has recently shown that twenty-five per cent, of cases of the splenic va- 
riety of the disease presented a history of ague or of exposure to malaria. 
But certainly that origin cannot be suggested for the great majority of 
cases. All forms of the disease appear to be more common in men than 
in women. 

1 ' Transactions of Pathological Society,' vol. xxix. 

34 



530 



DISEASES OF THE VASCULAR ORGANS. 



Morbid anatomy — The anatomical substratum of leucocythaemia has 
already been discussed at some length under the head of lymphadenoma, 
in an earlier portion of this work. We there pointed out that lymph- 
adenoma is a form of disease especially apt to attack the lymphatic glands 
and spleen — sometimes the one or the other exclusively, but more fre- 
quently both, and then many other organs and tissues at the same time or 
consecutively. We also adverted to its influence on the condition of the 
blood. In a considerable number of cases (to which Dr. Wilks has given 
the name of anaemia lymphatica, Trousseau that of adenia) the disease is 
attended in its progress with gradually increasing but simple anaemia, the 
blood becomes progressively more and more watery, and the blood-corpuscles 
(red and white in equal ratio) gradually disappear. In other cases, which 
are undistinguishable anatomically from these, and in which the general 
symptoms and progress of the disease are as nearly as possible identical, 
progressive anaemia also takes place ; but it is an anaemia distinguishable 
from the former by the fact that, while the red corpuscles disappear, the 
white multiply until,- in advanced cases, they nearly equal their red com- 
panions in number, and after death are not unfrequently found aggregated 
in pale clots or thick creamy masses in the terminal branches of the pul- 
monary artery, the cavities of the heart, and the systemic vessels. We 
also pointed out, in our account of lymphadenoma, that two varieties of 
leucocythaemia had been distinguished by Virchow : one in which the 
spleen was involved, and where the superabundant white corpuscles were 
of the normal size of these bodies ; one in which the glands were impli- 
cated, and where the abnormal leucocytes were smaller than natural. It 
is an important fact, however, which has been clearly established by the 
discussion 1 on lymphadenoma at the Pathological Society : that leucocy- 
thaemia is much more frequently associated with lymphadenoma originat- 
ing in, and limited to, the spleen, than with similar disease of lymphatic 
glands ; and that lymphadenoma exhibiting distinctly malignant characters 
seldom or never causes special changes in the blood. 

Symptoms and progress Splenic leucocythaemia comes on insidiously. 

In some cases it is the painless enlargement of the abdomen which first 
attracts attention. In some cases gradually increasing asthenia, pallor, 
and shortness of breath are complained of for some time before the con- 
dition of the abdomen is observed. And occasionally all the other phe- 
nomena are preceded by irregularly recurring slight febrile paroxysms. 
But, under any circumstances, the patient gradually gets anaemic, loses 
flesh and strength, becomes incapable of exertion, short-breathed, and 
liable to palpitation, and the abdomen gets large, solid, and heavy; and 
then careful examination reveals the fact that the spleen is enlarged, per- 
haps enormously, extending not only upwards into the chest, but probably 
downwards to the groin, and across the mesial line of the abdomen. The 
progress of the case is slow, but as it goes on: the patient's languor and 
debility gradually increase; his pulse becomes frequent — up to 90 or 100; 
his breath continues short, especially on exertion or under excitement, 
and is from time to time deep-drawn or sighing, and often attended with 
yawning ; his tongue remains fairly clean ; his appetite is variable, but, 
on the whole, probably pretty good ; there may be some clamminess of 
mouth, if not actual thirst ; and diarrhoea is liable to ensue ; the urine is 
generally fairly abundant, acid, and loaded with urates, and often contains 



1 ' Transactions of Pathological Society,' vol. xxix. 



IDIOPATHIC ANEMIA. CHLOROSIS. 



531 



albumen in small quantity, with hyaline or granular casts ; hemorrhages 
are apt to take place, either into the subcutaneous or subserous tissues, or 
from the mucous surfaces, more especially that of the nose; and occasion- 
ally anasarca, mainly of the lower extremities, and even accumulations of 
fluid in the serous cavities, supervene. Febrile symptoms are sometimes 
absent from first to last ; sometimes the patient is liable to paroxysms, 
coming on at long and irregular intervals ; and occasionally he suffers, 
either during his whole illness or towards its close, from well-marked hectic 
fever — the temperature rising during the exacerbations to 101°, 102°, or 
even 103°. With this are necessarily associated night-sweats and other 
characteristic features of hectic. Besides hemorrhages and dropsical effu- 
sions, other complications are apt to supervene, especially during the later 
periods of the disease ; among which may be enumerated splenic periton- 
itis, pulmonary or pleural disorders, and the development of subcutaneous 
abscesses. It should be added that the spleen does not necessarily enlarge 
progressively during the whole duration of the patient's illness ; but that 
it often becomes stationary after a while, or even liable to slight variations 
of bulk. Further, the blood always presents a large excess of white cor- 
puscles. So far as is known, splenic leucocythsemia is invariably fatal 
(probably within six months or two years of its first appearance) either 
by simple asthenia, or by this in conjunction with the effects of some inter- 
current malady. 

Lymphadenoma, affecting the lymphatic glands primarily, generally 
begins in a group of these bodies ; and then either remains limited to this 
group, or, as more commonly happens, gradually involves the lymphatic 
glands and tissues of other parts of the body. The progress of the disease 
is generally attended with more or less ansemia, and symptoms not unlike 
those of splenic leucocythaemia ; but the development of tumors forms an 
essential element in the case ; and death is likely to ensue ultimately, as 
in other forms of malignant disease, not merely from gradually increasing 
debility, or intercurrent disorders, but from the involvement in the specific 
growth of vital or important organs, such as the larynx and trachea, heart, 
lungs, or abdominal viscera. 

Treatment The successful treatment of splenic leucocythsemia, as also 

of lymphadenoma, appears to be altogether beyond the resources of our 
art. We can do little if anything beyond treating symptoms as they arise, 
and promoting the health of the patient by attention to diet, hygienic 
management, and the exhibition of iron or other tonics. 



VII. IDIOPATHIC ANEMIA. CHLOROSIS. 

Definition — Aneemia is the name applied to a condition in which there 
is diminution of the solid constituents of the blood and in particular of the 
red and white corpuscles, attended with pallor of the general surface and 
of the mucous membranes, palpitation, feebleness and rapidity of pulse, 
panting respiration, sighing and yawning, headache, restlessness, func- 
tional disturbance of the organs of sight and hearing, tendency to faint, 
and general debility. Idiopathic anaemia is a form of ana2mia coming on 
independently of any organic lesion or dyscrasia, and chiefly in young 
women. In the last case it is usually termed chlorosis. 



532 



DISEASES OF THE VASCULAR ORGANS. 



Causation. — Anaemia is a frequent complication or result of many morbid 
conditions : of the dyscrasiae, for example, connected with tuberculosis, 
malignant disease, syphilis, and malarious affections, and of the more or less 
frequent and copious hemorrhages which take place under various circum- 
stances from one or other of the mucous tracts. 

Idiopathic anaemia is occasionally met with in men ; it also affects women 
of mature age, and those in whom menstruation is disappearing. But it 
is especially a disease of young females, from the period of commencing 
puberty to about twenty-five. Many causes have been assigned for it, 
such as deficient and unsuitable diet, unwholesome habitations, sedentary 
habits and want of fresh air, late hours, emotional affections, masturbation, 
and especially functional uterine or ovarian disturbances. It may be 
readily admitted that some of these conditions may be predisposing causes 
of chlorosis, it is certain that some of them may be consequences of it, but 
it is very doubtful if any of them can lay claim to being the exciting cause. 
The nature of this cause, indeed, is still veiled in mystery. 

Symptoms and progress — Chlorosis generally first reveals itself by 
gradually increasing paleness of the surface, palpitation, breathlessness on 
exertion, loss of muscular power, and more or less gastrodynia and impair- 
ment of the digestive functions, without loss of flesh. To these phenomena, 
however, many others sooner or later are superadded. The pallor usually 
becomes extreme — the general surface assuming a white or sallow wax- 
like appearance ; the face, indeed, may present a greenish tinge — whence 
the name chlorosis. But the loss of color takes place in the mucous mem- 
branes as well as the skin, and is for the most part strikingly obvious in 
the palpebral conjunctivae, and in the lips and gums, which become in 
some cases scarcely distinguishable in tint from the skin itself. It may 
be pointed out, however, that, even in advanced cases, a fallacious bloom 
may appear in the cheeks under the slightest emotional excitement. Pal- 
pitation is a prominent symptom, and painfully apparent to the patient 
herself; it is rarely absent, and is always aggravated either by mental ex- 
citement or by bodily exercise; the rapidity with which the heart's contrac- 
tions succeed one another is sometimes extraordinary, and not unfrequentlv 
their rhythm becomes remarkably irregular. The development of abnor- 
mal sounds in the heart and bloodvessels, independent of organic lesions, 
is of common occurrence and highly characteristic ; a soft systolic murmur 
is frequently to be heard over the situation of the aortic or pulmonic valve, 
and along the course of the ascending arch and innominate artery ; mur- 
murs, coincident with the cardiac systole, may be developed more readily 
than natural by pressure on the subclavian, carotid, and other large 
arteries ; and, lastly, continuous murmurs, more or less musical and varying 
from a feeble hissing to a deep droning {bruit de diable), may readily be 
evoked by the pressure of the stethoscope on the veins of the neck, more 
especially on the right side. The respirations are usually more rapid and 
shallow than in health, and occasionally become extraordinarily frequent, 
particularly under the influence of bodily exertion or emotional disturbance : 
and the patient consequently complains of shortness of breath and inability 
to exert herself. There is usually some impairment of the digestive func- 
tions, with uneasiness or weight after food, flatulence, loss of appetite, and 
pain more or less severe and varying in character, either in the epigastric 
region or between the shoulders, in the left hypochondrium, or some neigh- 
boring part. It is apparently in chlorotic girls that perforating ulcer of 
the stomach is most common, on which account their dyspeptic symptoms 



IDIOPATHIC ANEMIA. CHLOROSIS. 



533 



must always be regarded with suspicion and treated with care. The 
bowels are usually constipated. The urine, for the most part, is abundant, 
pale, and of low specific gravity. There is not unfrequently leucorrhoea ; 
and although the menstrual function in some cases continues to be nor- 
mally performed, it is usually at fault : the flow is sometimes regular, but 
scanty ; sometimes profuse or too frequent, or attended with severe pain ; 
most commonly there is amenorrhea. Trousseau points out, and probably 
with truth, that the sexual appetite is diminished rather than (as is often 
asserted) increased. The muscular system becomes generally enfeebled ; 
but the subcutaneous fat undergoes little or no diminution — sometimes, 
indeed, becomes increased — so that the patient, as a rule, presents more 
or less embonpoint. Some degree of anasarca, especially in the lower 
extremities, occasionally supervenes in the course of the disease. The 
nervous phenomena which are apt to attend chlorosis are many and 
various : there is usually more or less listlessness, inability of application 
to any pursuit or even train of thought, lowness of spirits, and irritability 
of temper; usually, also, chlorotic girls complain of neuralgic pains, some- 
times in the face and head, sometimes in the intercostal muscles, sometimes 
in the internal organs or extremities. Again, they are not unfrequently 
hysterical, have depraved appetites, or suffer from paralysis or convulsions, 
or even become maniacal. It is rare for the chlorosis of young women to 
terminate fatally, or even to lead to the development of tuberculosis or 
any other organic disease, excepting, perhaps, ulcer of the stomach. Under 
proper treatment the patient generally recovers in the course of a few 
weeks or a month, but is liable to have relapses. 

But anaemia coming on without obvious cause, especially in men, and in 
women above the age at which chlorosis is common, is occasionally alto- 
gether unamenable to treatment, and terminates sooner or later in death. 
During life such cases are liable to be mistaken, at any rate for a time, for 
cases of visceral cancer, undetected hemorrhages from the bowels, or Addi- 
son's disease without melasma. To this affection, the symptoms of which 
are in the main identical with those of the last-named disease, the desio-- 
nation of ' pernicious anaemia' is sometimes given. 

[This is the only affection to which it is usual to give the name of idio- 
pathic or essential anaemia. It was first described by Addison, and has 
since his time been fully recognized in England and in the United States. 
In Germany, on the other hand, it appears to have been unknown until 
recently, when it received the designation of progressive pernicious anae- 
mia. Its approach is as insidious as that of Addison's disease, to which 
it certainly presents many points of resemblance. The discoloration of the 
skin peculiar to that disease is of course wanting; the skin being usually 
blanched as in the ordinary forms of anaemia. Occasionally, however, it 
may be of a dirty-yellow color. It occurs in persons of all ages and of 
both sexes. It would appear, however, to be more frequent in women than 
in men. Repeated pregnancies seem to predispose to it, and so do the de- 
pressing emotions. Poverty has also been asserted to be an exciting cause, 
but if it occurs oftenest among the poor, it is also occasionally met with 
among the well-to-do. 

In addition to the more usual symptoms of anaemia, such as pallor, loss 
of strength, cardiac murmurs, and venous hum, patients often suffer from 
derangements of the stomach and bowels; nausea, and vomiting being 
not uncommon. Indeed these have been so persistent in the beginning 
in some cases as to have given rise to the suspicion, especially when 



534 



DISEASES OF THE VASCULAR ORGANS. 



accompanied by tenderness of the epigastrium, that malignant disease of 
the stomach was present. Hemorrhages from the nose, gums, rectum, and 
in women from the genital organs, occasionally occur, and very much in- 
crease the anaemia. Petechias, both cutaneous and retinal, are also not 
infrequent. The latter are often of large size and materially interfere with 
vision. They depend, as do the hemorrhages, upon fatty degeneration of 
the vessels. In a few cases dropsy of the feet and legs, with albuminuria, 
has been observed, but these symptoms are often absent. The blood is 
usually thin and watery. Under the microscope the white corpuscles 
generally appear to be increased in number, but this increase is only rela- 
tive and consequent upon the diminution of the red, which are sometimes 
reduced to one-sixth or even one-tenth of the normal number. They are 
in many cases smaller than in health and defective in shape, having lost 
their biconcave form. Fever of an irregular type is not an uncommon at- 
tendant upon the disease, the temperature occasionally rising to 104°. 

The disease, it is believed, invariably terminates in death, and its course 
to this termination is generally steadily progressive. In a few cases, just 
as in Addison's disease, remissions occur which may delude the patient 
and his physician into the belief that recovery is going to take place, but 
after a short time the symptoms invariably recur with their former severity. 
The usual duration of the disease is from six weeks to six months, but it 
is sometimes much longer ; cases having been reported in which the patient 
lived for eighteen months. 

Post-mortem examinations have thrown no light upon the pathology of 
this disease. In addition to the extravasations of blood in various parts 
of the body and the fatty degenerations of the vessels already referred to, 
fatty degeneration of the liver and kidneys has been found in many cases. 
Changes in the medulla of the bones is also said to be not infrequent. 
This has led one observer to conclude that it is the medullary form of 
pseudo-leucocythaemia. 

Treatment appears to exercise no influence upon the course of this affec- 
tion. Temporary improvement has, however, occasionally followed the 
administration of cod-liver oil, iodide of iron, and remedies of this class.] 

Pathology The pathology of idiopathic anaemia is not at all under- 
stood. Trousseau regards chlorosis as a neurosis, looking upon the morbid 
condition of the blood as secondary to the nervous affection. Some con- 
sider the reproductive organs, others the chylo-poietic viscera, as being 
primarily at fault. It is natural to refer the diminution of the corpuscular 
elements of the blood to some functional disturbance or organic lesion of 
the lymphatic tissues ; but unfortunately nothing has yet been detected in 
their condition to justify this view. It is attempted to make a distinction 
between ordinary forms of anaemia and chlorosis by reference to the com- 
position of the blood. Ordinary anaemia, it is said, is characterized by the 
diminution in equal proportion of all the solid constituents of that fluid, 
w T hereas in chlorosis it is the corpuscular elements which alone are deficient. 
It is clear, however, that this distinction can be of little value : for it is 
well known that when anaemia is caused by abstraction of blood, the cor- 
puscles and other organic principles being removed in equal proportion, 
the albuminous and other such matters are far more speedily restored to 
that fluid than the corpuscles, and that hence (whatever may have been 
the patient's condition at first) a time speedily arrives in which the blood 
presents the assumed typical characters of chlorotic blood. 



PURPURA. 



535 



Treatment. — It is no doubt important in the treatment of chlorosis to 
obviate all possible sources of ill-health, and especially to secure for the 
patient change of scene, good air, moderate exercise, early hours, innocent 
amusement, and wholesome diet. But of far greater importance than these 
is the administration of iron. This metal, indeed, appears to be almost a 
specific remedy in this disease. Different authorities recommend different 
preparations ; but they are probably all (if given in equivalent doses) 
equally efficacious. They are generally best administered in combination 
with some vegetable bitter or stomachic, such as quinine, cinchona, or 
calumba ; and in association with occasional purgatives, such as aloes and 
myrrh pills, to obviate the obstinate constipation which is so often present. 
The form in which iron should be given must be determined by the special 
circumstances of the case. If dyspeptic symptoms are predominant, the 
tartrate of iron, in combination with an alkali and calumba or quassia, 
may be most suitable. It may even, under such circumstances, be well 
to delay the use of iron until some amendment in the condition of the 
stomach has been obtained by other measures. If menorrhagia be present, 
the perchloride of iron or the sulphate, in combination with mineral acids, 
may prove especially serviceable. Zinc is believed by some to have 
similar virtues to those of iron. In a large number of cases the ferrugin- 
ous treatment cures not only the chlorosis, but the various complications — 
dyspeptic and uterine — which accompany the chlorosis : but that is not 
always the case, and just as it is frequently necessary to deal with the 
dyspepsia directly, so it may be essential to direct our treatment to the 
cure of the uterine derangement. In so-called ' pernicious anaemia' all the 
usual remedies appear to fail. 



VIII. PURPURA. 

Definition — Extravasations of blood, in the form of points, petechias, 
vibices, or ecchymoses, are not uncommonly observed beneath the surface 
of the skin in various diseases, and under many other conditions, and are 
then often termed purpuric. Not unfrequently these subcutaneous ex- 
travasations (especially if due to constitutional disorders) are associated 
with similar extravasations into the solid organs, and beneath the serous 
and mucous membranes, and with more or less abundant escape of blood 
from these surfaces. Such extravasations are especially common in typhus, 
smallpox, measles, scurvy, obstructive heart affections, and liver disease, and 
are also met with in scarlet fever, diphtheria, pyaemia, and embolism. They 
further occasionally complicate certain skin diseases, more especially some 
forms of erythema and urticaria, and may even be induced by mere ex- 
posure to atmospheric influences. But to none of these affections, how- 
ever severe they may be, can the term purpura be properly applied. 

Purpura, in the strict sense of the term (the morbus maculosus Werl- 
hofii of the Germans) is the name given to a disorder characterized by 
such hemorrhages as have been above specified, but unconnected, so far as 
we know, with any local mischief or general specific disease. 

Causation — The causes of purpura or the condition under which it 
arises are exceedingly obscure. It occurs at all ages, but mostly in young 
children of both sexes. It is frequently observed amongst those who are 



536 



DISEASES OF THE VASCULAR ORGANS. 



sickly, underfed, or surrounded by unwholesome sanitary conditions ; but 
it is also met with amongst the robust and healthy-looking, and those 
whose hygienic and other circumstances appear to be unexceptionable. It 
is certainly not due to insufficiency of vegetable food, nor has it been 
traced to any special dietetic default. It is apt to recur ; and conse- 
quently it is not uncommon to find a child (and apparently a healthy 
one) having periodical relapses, at intervals of three, six, or even twelve 
months. 

Symptoms and progress Purpura is sometimes ushered in with vague 

premonitory symptoms, such as lassitude, loss of appetite, headache, and 
aching in the limbs, lasting from one to perhaps three or four weeks. In 
many cases, on the other hand, the characteristic lesions suddenly manifest 
themselves in the midst of apparently good health. The skin becomes 
more or less thickly studded with circular, deep red, almost black spots, 
varying from about a quarter of an inch in diameter downwards, which 
are unattended with any abnormal sensation, are not elevated above the 
level of the skin, and do not fade on pressure. They are usually most 
abundant on the lower part of the trunk and the lower extremities, but are 
by no means confined to these situations ; and not unfrequently extravasa- 
tions take place into the eyelids, and beneath the conjunctivae and the mu- 
cous surface of the tongue, lips, gums, and other parts within the cavity 
of the mouth. These spots go through the ordinary changes of color which 
characterize bruises, and, thus fading away, usually disappear completely 
in the course of a few days. Successive crops of petechias, however, com- 
monly appear from time to time, and thus the disease may be continued 
for two, three, or four weeks, and sometimes for a still longer period. 
Larger extravasations — vibices and ecchymoses — are usually associated in 
a greater or less degree with the eruption above described. But these are 
generally deeper seated, present less abrupt margins, are attended with 
swelling, and not unfrequently first reveal their existence as deep-seated 
bruises do, by the gradual diffusion and coming to the surface of their 
more or less modified coloring matter. They are not unfrequently the 
result of mechanical violence. There is always a tendency in these cases 
(more pronounced in proportion to their severity) for hemorrhages to take 
place from the mucous surfaces. Thus, there may be epistaxis, bleeding 
from the gums or other parts within the mouth, haemoptysis, or bleeding 
from the stomach or bowels, kidneys or other parts of the urinary tract, 
uterus or vagina. In many cases the hemorrhage is small in quantity 
and of little importance ; but occasionally it is profuse and frequently re- 
peated. 

When the affection is slight, the patient may seem during its continuance 
to be in good general health ; more frequently, perhaps, he suffers from a 
continuance of such symptoms as may have ushered in the attack ; some- 
times the progress of the case is attended with febrile symptoms of a re- 
mittent type : but when profuse hemorrhages take place, the symptoms due 
to the loss of blood get developed. Not only does the patient then become 
excessively pallid, but his pulse increases in frequency and gets more or 
less jerking ; he has noises in his ears, dilated pupils, indistinctness of 
vision, with muscae and headache ; he yawns, becomes uneasy and restless, 
and sometimes falls into delirium, mania, or convulsions. Death is usually 
due to asthenia or syncope. His temperature is sometimes lowered, some- 
times, on the other hand, considerably elevated. The milder form of pur- 
pura is sometimes termed p. simplex; the more severe, p. hcemorrhagica. 



SCURVY. 



537 



Morbid anatomy throws little light on this disease. Hemorrhages 
similar to those beneath the skin are sometimes discovered in the sub- 
serous and submucous tissues, and less frequently in the parenchyma of 
various organs, more especially the lungs, heart, and kidneys. Extreme 
fatty degeneration of the muscular fibres of the heart has been detected in 
cases fatal from repeated hemorrhage after long continuance of the disease. 
The blood seems to present no constant departure from the normal condi- 
tion. It is curious, however, that Dr. Parkes has, in two cases which he 
has examined, detected in this fluid an excess of iron together with a gene- 
ral diminution of the solid constituents. It seems more probable, however, 
that the primary morbid condition is in the capillary and other small ves- 
sels than in the blood, and that the latter escapes into the tissues in conse- 
quence of their rupture. 

Treatment The principles of treatment of purpura are as little under- 
stood as its pathology. The majority of patients get well in the course of 
a week or two without treatment. The severer cases are unfortunately 
apt to go on from bad to worse, whatever treatment be adopted. A cer- 
tain prima facie resemblance which purpura presents to scurvy has induced 
a common belief that antiscorbutic remedies — fresh vegetables, citric acid, 
and potash — are indicated here also. Experience, however, does not con- 
firm the truth of this opinion. Among the remedies which have been 
chiefly recommended are perchloride of iron, acetate of lead, arsenic, digi- 
talis, turpentine, and gallic and sulphuric acids. If the discharge of blood 
be profuse, one or other of these drugs may be prescribed ; and at the 
same time the patient should be kept quiet and cool, and should have ice 
or ice-cold drinks given to him. Hemorrhages taking place from accessible 
parts may, of course, be treated by local measures. If asthenia be extreme, 
it may be absolutely necessary to give alcoholic stimulants. On the whole, 
tonic treatment is indicated in those persons who have a tendency to pur- 
pura and in those who are convalescent from it. 



IX. SCURVY. (Scorbutus.) 

Definition — Scurvy may be regarded as a peculiar form of anaemia 
arising from deficiency of vegetable diet, and attended with a tendency to 
the occurrence of hemorrhages, profound impairment of nutrition, and 
great mental and bodily prostration. 

Causation — Scurvy formerly occurred largely among sailors during 
long voyages. It has often broken out in armies on active service and 
among populations suffering from famine. It still occurs from time to time 
under these various conditions ; and is occasionally met with as a sporadic 
affection among persons who are ill-fed, or whose diet has been, from some 
cause or other, too exclusively animal. It is needless to go into a history 
of scurvy, or to discuss the various hypotheses which have been propounded 
in reference to its causation. It will be sufficient to state that its origin 
has been clearly traced to insufficiency or total want of fresh vegetables ; 
but among these must not be included corn and the other graminaceag, or 
peas. It is still uncertain, however, to what constituent or constituents, 
common to vegetables, their virtue is due. Dr. Garrod believes it to re- 
side in the salts of potash ; others maintain that it dwells in the citric and 



538 



DISEASES OF THE VASCULAR ORGANS. 



other vegetable acids which they so often contain. There are objections, 
however, to both of these views ; for the antiscorbutic powers of vegetables 
do not appear to be proportionate to the potash salts they contain, and pot- 
ash salts alone are probably inefficacious ; and potatoes, which are power- 
fully antiscorbutic, are devoid, or nearly so, of vegetable acids. The 
constant use of salt meat, and long-continued exposure to privation and 
other such causes of ill- health, can only be regarded as indirectly favoring 
the production of scurvy. 

Symptoms and progress. — The early symptoms of scurvy maybe easily 
misunderstood when presented by sporadic cases ; they cannot, however, 
fail to attract attention when they arise simultaneously or in rapid suc- 
cession among a number of persons equally exposed to the conditions 
which are liable to give origin to the disease. They are : rapidly progres- 
sive anaemia, indicated by a dirty-looking, pallid, sallow, or earthy aspect ; 
growing indisposition for bodily exertion ; pains of a rheumatic character 
in the back and limbs ; and more or less mental apathy or depression ; 
while probably the tongue continues clean, though becoming large, flabby, 
and indented by the teeth, the appetite remains good, and the bowels are 
constipated. But soon other phenomena arise : petechial spots appear, 
first on the lower extremities, and then on other parts of the surface ; and 
to these presently succeed large subcutaneous extravasations, and sooner 
or later, colorless puffy swellings, which seem to be due to deeper-seated 
and more copious hemorrhages, and the nature of which gets revealed ere 
long by the occurrence of bruise-like staining of the tissues superficial to 
them. These puffy SAvellings affect mainly the popliteal spaces, the cor- 
responding parts of the elbows, the anterior aspect of the lower part of 
each leg, and the regions behind the angles of the jaw — interfering with 
the movements of these parts, and causing more or less pain and tender- 
ness. Similar extravasations take place especially into the loose connec- 
tive tissue in and about the eyelids, leading to considerable puffiness and 
bruise-like discoloration of these parts, and to sanguineous accumulation in 
the ocular sub-conjunctival tissue. Concurrently with the appearance of 
these hemorrhages the gums swell at their edges, and rapidly increase in 
bulk until they form lobulated masses, which rise up around the teeth, and 
sometimes hide them altogether from view. These masses are spongy, 
deep-red or livid, and insensitive, but apt to bleed ; they readily ulcerate 
or slough, and impart a fetid odor to the breath. The teeth get loose, and 
frequently drop out. The same tendency to ulcerate or slough is mani- 
fested in a greater or less degree by all parts of the surface of the body, 
but especially by those which are the seats of the puffy swellings above 
adverted to, and by those which present the cicatrices of former injuries. 
The slightest scratch, pressure, or blow is often sufficient to induce these 
destructive processes. Along with these phenomena the patient's anaemia 
increases ; his face gets puffy ; more or less anasarca takes place in his 
lower extremities ; he becomes breathless ; his heart acts rapidly and 
feebly ; and even though retaining, as he probably does, a good deal of 
muscular strength, he is liable on the slightest exertion, even that of rising 
in bed, to attacks of sudden syncope, which are attended with the utmost 
danger to life. During the later periods of the disease the appetite often 
fails ; the patient suffers from looseness of bowels, the motions frequently 
being highly offensive, and containing more or less blood; he has disturb- 
ance of vision (hemeralopia, nyctalopia), singing in the ears, vertigo, 
want of sleep, and occasionally delirium. His intellect, however, remains 



SCURVY. 



539 



for the most part unaffected. In many cases during the progress of the 
disease thoracic complications arise, especially effusion into the pleurae, 
congestion of the lungs with extravasation of blood into their tissue, con- 
gestion of the bronchial tubes, cough, and sanguinolent expectoration, not 
unfrequently attended with a marked gangrenous odor. The duration of 
scurvy is uncertain, but it may extend over many weeks or even months. 
Death is usually due to sudden syncope or gradual asthenia, and may at 
any time be hastened by the occurrence of hemorrhage, ulceration, thoracic 
affections, or other complications. Recovery is generally rapid under 
suitable treatment. But the patient is liable to remain in enfeebled health, 
and ultimately perhaps to fall a victim to pulmonary phthisis or some other 
chronic visceral disorder. 

Morbid anatomy The morbid anatomy of scurvy accords with the 

symptoms of the disease ; there is tendency to rapid decomposition ; extra- 
vasations of blood in various stages of transformation may be found, not 
only in the superficial regions already specified, but in the substance of 
the lungs, beneath the pleurae, in the walls of the heart, in the sub-peri- 
cardial tissue, in the intestinal parietes, and beneath the peritoneal mem- 
brane. Sanguinolent serum also may be found in the various serous 
cavities. In other respects the condition of the viscera is very variable. 
The lungs, liver, and spleen m \y or may not be congested; the heart may 
be contracted and empty, or distended with black blood. The brain 
generally is healthy. The blood contains an excess of fibrine, but presents 
a diminution in the number of the red corpuscles, and an abnormally low 
specific gravity. 

Treatment. — The only effectual treatment of scurvy is the restoration to 
the dietary of those articles of food to the want of which the disease has 
been traced — namely, vegetables, and especially those, or those substances 
extracted from them, which contain citric acid and potash. Among the 
ordinary articles of diet which are efficacious in this respect must be enu- 
merated potatoes, yams, onions, carrots, turnips, green vegetables of all 
kinds, inclusive of mustard and cress and scurvy grass ; lemons, oranges, 
limes, grapes, and apples ; and, among their derivatives, lemon- and lime- 
juice and sauerkraut. The provision enforced in emigrant ships, and which 
has been found effectual in preventing the occurrence of scurvy is, that 
each person must have weekly at least eight ounces of preserved potatoes 
and three ounces of other preserved Vegetables (carrots, onions, turnips, 
celery, or mint), besides pickles, and three ounces of lime-juice. And 
among the suggestions issued by the Board of Trade to shipowners is the 
following : — namely, that each man should have at least two ounces of 
lime- or lemon-juice twice a week, to be increased to an ounce daily if any 
symptoms of scurvy manifest themselves. The importance of additionally 
supplying scorbutic patients with good nourishing diet, of taking precau- 
tions against sudden syncope, and of relieving by local applications the 
bleeding ulcerated gums, and ulcers which may exist in other parts, is of 
course obvious. 



540 



DISEASES OF THE VASCULAR ORGANS. 



[HAEMOPHILIA. HEMORRHAGIC DIATHESIS. 

(Bleeder Disease.) 

Definition Haemophilia is the name now generally given to a condi- 
tion characterized by a tendency to frequent and obstinate bleedings, either 
occurring spontaneously or following upon slight injuries. With this ten- 
dency there is frequently combined one to swelling of the joints. The 
disease is, as a rule, congenital and hereditary, and usually lasts through- 
out the life of the patient. In a few cases, however, it is said to have 
originated in adult life, and in others the idiosyncrasy appeared to have 
been lost with advancing years. It has long been recognized and is of 
more frequent occurrence in the United States than might be supposed 
from the almost complete silence of American physicians in regard to it 
since the appearance of the papers of Drs. Otto, Hay, and Smith at the 
beginning of the present century. This fact and the importance of the 
subject seem to render necessary the following brief notice of it. 

Causation The prominent part played by hereditary predisposition in 

the production of this disease was recognized by most of the early observers, 
and has been fully established by recent investigations. Thus Dr. Legg 
found that, out of 98 families in which it occurred, there had been a dis- 
position to hemorrhage in the parents, grandparents, or cousins in 52. 
Immermann's researches go also to prove the same point ; for they show 
that the 650 cases he was able to collect were distributed among 219 fami- 
lies, or, in other words, that there were nearly three bleeders to every 
family affected. Statistics show that the disease is much more frequently 
met with in the males of these families than the females ; the proportion 
being about 13 to 1. Indeed, the typical form is rarely observed in the 
latter, who either escape it wholly or present only a few unimportant 
symptoms ; being usually not more liable than other women to lose an 
undue amount of blood even during menstruation or parturition. They 
possess, however, on the other hand, even when not bleeders themselves, 
in a much greater degree than the men, the power of transmitting the 
diathesis to their children. 

In regard to the influence exercised by race in predisposing to this dis- 
ease some difference of opinion exists. By some authors it is asserted to 
occur with greater frequency in Germany than in any other country, and 
it is certainly true that in a large number of the reported cases the patients 
were Germans. But this may be explained by the general interest felt 
there in the disease, which has led to a careful recording of almost every 
case. It is said also to be more common in northern than in southern 
countries. According to Immermann but few cases have been reported 
from France, and none from Italy, Spain, Portugal, Greece, or Turkey. 
A remarkable predisposition seems, however, to exist in the widespread 
Hebrew race, since the disease has been repeatedly noticed among these 
people in connection with the rite of circumcision; and of the total num- 
ber of bleeder families, thus far reported, a considerable number have been 
•Jewish. The elevation of a region does not bring with it an immunity, 
as cases are reported of bleeders and families of bleeders from the high 
Alpine valleys of Switzerland, as well as from the lowlands of Holland. 
The disease is thought by some authors to prevail more in damp than in 
dry localities. 

Haemophilia has been observed in persons of every variety of tempera- 



HAEMOPHILIA. HEMORRHAGIC DIATHESIS. 



541 



ment and constitution. Immermann and others agree, however, that it is 
encountered with the greatest frequency in individuals possessing "a cer- 
tain delicacy and transparency of the general integuments, together with 
a superficial position and marked fulness of the vessels, particularly the 
veins." It would appear, therefore, to be more common in blondes than 
brunettes, but the latter do not by any means enjoy an exemption. The 
younger children in bleeder families are more likely to suffer than the older. 
The subjects of the disease, except of course immediately after a hemorrhage, 
present nothing in their appearance by which they can be distinguished from 
other persons. 

The diathesis when present generally manifests itself very early in life; 
indeed, in a large proportion of the cases, in infancy or childhood. Thus 
Grandidier found that, out of 65 boys, positive signs of the disease had 
appeared in 62 before the end of the tenth year. Perhaps, on the whole, 
these signs most frequently make their appearance at about the close of the 
first year, because the infant at that time begins to crawl about and is con- 
sequently more exposed to injuries than before. Exceptionally they are 
observed even much earlier. Thus Yirchow states that children have 
sometimes bled during birth ; and death has not infrequently taken place 
as the result of hemorrhage after circumcision. On the other hand, no 
special danger seems to attend the falling off of the stump of the umbilical 
cord. According to Legg, the latest age at which haemophilia has appeared 
is between 21 and 22. A father and son became subject to profuse bleed- 
ings first at this age, and both died of hemorrhage. 

Symptoms. — Two varieties of hemorrhage are observed in haemophilia : 
1st. External hemorrhages in which the blood is poured out from the free 
surface of the bleeding part ; and 2d. Interstitial hemorrhages in which 
the extravasation takes place into the tissue itself. Both varieties occur 
spontaneously or as the result of injuries. The seat of a traumatic hem- 
orrhage will of course vary with that of the injury which caused it, and, 
as there is no part of the body which is absolutely protected from harm, 
there is, therefore, none from which it may not occasionally take place. 
Its most frequent seat is, however, the skin, and next to this the mucous 
membrane of the mouth and nose, as these are the parts most exposed to 
wounds or blows. A mere scratch or the prick of a pin is often sufficient 
to place life in danger. Death has, in several instances, followed the 
application of leeches, the cutting of the fraenum of the tongue, or the ex- 
traction of a tooth, the hemorrhage from the last of these causes being 
especially difficult to manage. Vaccination would appear not to be a very 
dangerous operation. A slight blow, which would produce no appreciable 
effect on a healthy person, often gives rise in a bleeder to an extensive 
ecchymosis, or even to an infiltration of the cellular tissue of the part, 
affected with blood. In some cases, indeed, tumors of enormous dimen- 
sions are caused by these extravasations. 

The spontaneous hemorrhages exhibit a marked predilection for certain 
tissues, especially the mucous membranes, and also frequently take place 
from several localities simultaneously. It is, therefore, not uncommon for 
bleeders to have attacks of epistaxis, haematemesis, haematuria, or bron- 
chorrhagia, without apparent cause. But the mucous membranes are the 
favorite seat of these hemorrhages, simply because their vessels are less 
well supported than those of the skin or other parts. When, however, the 
skin is inflamed, the seat of an interstitial hemorrhage, or otherwise in 
an unhealthy condition, it is obvious that this support to the vessels will 



542 



DISEASES OF THE VASCULAR ORGANS. 



be weakened, and that blood may be then poured out directly from the 
external surface. Ecchymosis and even blood -tumors may, it is said, also 
occur spontaneously ; but it is, of course, possible that in these cases a 
slight injury has been overlooked. The spontaneous hemorrhages are often 
preceded by symptoms indicating local congestion. 

In the external hemorrhages of haemophilia, whether traumatic or spon- 
taneous, the blood generally oozes from the surface and does not flow in jets, 
as would be the case if an artery of any size were its source. A very con- 
siderable amount of blood is nevertheless often lost in this way in a few 
hours ; the bleeding usually persisting in spite of the use of all the ordinary 
haemostatics. The ecchymoses generally pursue the same course as when 
occurring under other circumstances. The blood-tumors may occasionally 
undergo suppuration, but fortunately they more commonly disappear grad- 
ually by absorption. 

The sufferer from haemophilia is liable to another affection, which is 
often the cause of more annoyance to him than the hemorrhages. This is 
the inflammation of the joints, which is attended generally with a good 
deal of pain and swelling, and occasionally with a high degree of febrile 
reaction. The larger joints are more frequently affected than the small, 
the knee joints being especially apt to suffer. So prominent is this compli- 
cation in some cases, that it has given rise to the belief that the disease is 
closely allied to rheumatism. 

Recent careful analyses of the blood in haemophilia have failed to show 
the existence of any essential difference between it and that obtained from 
perfectly healthy people. If examined at the beginning of a hemorrhage, 
it presents the usual color and coagulates firmly. In fact, it does not cease 
to be coagulable until late in the attack, when it will of course be found 
to be pale, watery, and deficient in red corpuscles. These characters are 
asserted by the early writers to be always present. Their mistake can 
only be explained by supposing that the blood was not examined until 
after the loss of a large amount had very materially altered its properties. 
Immermann maintains that the subjects of haemophilia recover their health 
after a hemorrhage with surprising rapidity, but this does not seem to be 
the general opinion ; for Legg says, on the contrary, that the blood which 
is lost is only very gradually regained. Depraved appetite has been 
noticed in a few patients, and other symptoms have been mentioned by 
authors as occasionally present, but as none of them seem to have any 
necessary connection with the disease, it is useless to recapitulate them 
here. Intercurrent diseases may, and do frequently occur in the course of 
haemophilia — bleeders enjoying, as a rule, no greater immunity from them 
than other people — and when they occur they run their usual course unaf- 
fected by the presence of the diathesis. 

Morbid anatomy and pathology The examination of the bodies of 

those who have died of haemophilia has revealed, in many instances, nothing 
that at all serves to explain the symptoms observed during life. If death 
lias occurred in consequence of hemorrhage, the extreme anaemia of the 
skin and tissues generally will be very striking. In cases in which ecchy- 
moses or blood tumors have been present during life, they will, of course, 
remain after death. Indeed, the former are found in such cases not only 
in the skin, but also occasionally in the mucous membranes and connective 
tissue. Certain alterations are, however, found with sufficient frequency 
to give them importance. These are principally connected with the vas- 
cular system, and consist in : 1. A striking superficiality and abnormal 



HAEMOPHILIA. HEMORRHAGIC DIATHESIS. 



543 



distribution of the cutaneous and subcutaneous vessels. 2. Great thin- 
ness and delicacy of the walls of the arteries, the intima being in many 
cases actually transparent. 3. An abnormal narrowness of the lumen of 
the large arteries, and especially of the aorta. 4. Some malformation of 
the heart. According to Legg, the heart retains an appearance, even in 
adult life, similar to that of the foetus. The muscular fibres in the ven- 
tricular and auricular walls are often wanting in places, being replaced by 
a membranous septum. Occasionally, the foramen ovale remains open. 
These appearances render it probable, in his opinion, that an arrest of de- 
velopment or backwardness of growth in the heart and bloodvessels takes 
place in this disease. Occasionally, however, the heart has undergone 
very decided hypertrophy. The spleen has been found, in a few cases, to 
be enlarged, softened, and engorged with blood, as compared with other 
organs, but Immermann regards this enlargement as an accidental compli- 
cation of no importance in the genesis of haemophilia. The changes in 
the joints do not appear to have been carefully studied. 

Morbid anatomy has, therefore, thrown very little light upon the path- 
ology of haemophilia, and consequently no theory as to its nature yet ad- 
vanced rests upon a perfectly secure foundation. As a matter of fact, 
none has met with general acceptance. The older observers, paying per- 
haps undue attention to the affection of the joints, which so often accom- 
panies it, regarded it as a modified form of gout or rheumatism. There is 
very little to support this view, for in neither of these diseases is there 
usually any tendency to hemorrhage, and it has therefore been abandoned. 
Others have referred the symptoms to a watery condition of the blood, 
Avhich they hold is always present, but it has been shown above that this 
view is also untenable, the blood, if examined at the outset of a hemor- 
rhage, presenting no character by which it can be distinguished from that 
of healthy persons. Another theory attributes the hemorrhages to the 
imperfect development of the vascular system ; the thinness of the walls 
of the vessels readily allowing the transudation of their contents. Dr. 
Legg believes that the symptoms of the disease are better explained by 
this theory than by any other ; but Immermann, while admitting that this 
condition of the vessels often exists, and that when present it must favor 
the occurrence of hemorrhages, teaches that these are really dependent 
upon plethora, which he maintains is generally present. In support of this 
theory, he, however, adduces only one undisputed observation, namely, 
that the spontaneous hemorrhages are often preceded by signs indicative 
of local congestion ; his assertions in regard to the toleration of excessive 
losses of blood and the rapid restitution of the lost blood not being borne 
out by facts. As his theory of the pathology of this disease cannot, there- 
fore, be accepted, it is not likely that his explanation of the almost com- 
plete immunity from it which women enjoy will be. He says that this is 
due to the fact that they are less liable to plethora than men. Moreover, 
he holds that menstruation acts as a powerful derivative, thus still further 
diminishing this liability, forgetting that the symptoms of haemophilia 
usually appear in boys, at an age much earlier than that at which menstru- 
ation is established in girls. On the whole, it would seem that the theory 
which Dr. Legg maintains is that which is best supported both by morbid 
anatomy and clinical observation. It also renders intelligible the occa- 
sional disappearance of the disease, as there is no difficulty in admitting 
that the nutrition of the walls of the vessels may occasionally improve. 



544 



DISEASES OF THE VASCULAR ORGANS. 



Diagnosis. — From what has preceded, it will readily be understood that 
the diagnosis of haemophilia is attended with much difficulty only in those 
cases in which the disease presents itself in an incomplete form, and in 
which the patient is apparently free from all hereditary tendency to it. 
Such cases are not infrequently met with in women who suffer from occa- 
sional attacks of spontaneous hemorrhage — epistaxis, for instance — and 
give rise to much embarrassment. The diagnosis is, on the other hand, 
generally easily made in boys, whose mothers are known to be either 
bleeders themselves, or the daughters of bleeders, and in whom hemor- 
rhages, both spontaneous and traumatic, have repeatedly occurred since 
birth. It would seem, therefore, to be of the first importance, in order to 
arrive at a correct conclusion as to the nature of the case, to inquire into 
the individual and family history of every patient. It should not be for- 
gotten, however, that the disease is sometimes, in spite of an inherited 
tendency to it, latent for many years, the symptoms having manifested 
themselves for the first time in tw r o cases after the age of twenty, and that 
still more rarely it occurs in adults in whom no such tendency exists. 

Prognosis. — This is, it need hardly be said, very unfavorable in haemo- 
philia, death occasionally taking place in the first attack. Such a result 
is, however, rare, life usually being prolonged until after several hemor- 
rhages. The mortality is greatest between the first and seventh years, 
and then progressively diminishes until the twenty-second year is reached, 
after which it rapidly declines. Thus, in a series of cases, collected by 
Grandidier, 212 in number, more than half (121) proved fatal before the 
patients had reached their eighth year, and in only 24 did they survive 
their twenty-second. Several instances are, however, on record of bleeders 
living to an advanced age, generally in consequence of the diathesis becom- 
ing latent. During an attack of bleeding, the prognosis will depend upon 
the amount of blood already lost, the age of the patient — the younger be 
is, the more likely will the attack be to prove fatal — his previous condition 
of health, and, to a certain extent, upon the cause and character of the 
wound. The bleeding which follows the extraction of a tooth is said to 
be especially dangerous, probably because it gives rise to a long-continued 
oozing, which is, at the same time, more difficult to check and less likely 
to cause fainting, and so to be arrested, than a free hemorrhage from an 
incised wound. Death may, however, take place in the course of a few 
hours, from a profuse loss of blood, as in the case reported by Wachsmuth, 
in which a woman died on her wedding-night from rupture of the hymen. 
Epistaxis is said to be the most serious form of the spontaneous hemor- 
rhages. 

Treatment — In considering the subject of the treatment of haemophilia 
the question naturally arises whether it is possible to eradicate so grave a 
disease from the community in which it exists. Inasmuch as no medicinal 
or hygienic means has yet been successful in modifying the diathesis, w r hen 
actually present, it would appear that the only certain way to do this is to 
prevent, where possible, the marriage of the women of bleeder families, 
as they alone possess in any great degree the power of transmitting it to 
their children. Legg, Immermann, and others, recommend that this 
should be done by legal enactments, but it is obvious that in the United 
States it can only be accomplished by calling attention to the tendencies 
which the offspring of such women must, in all probability, inherit. The 
subjects of haemophilia, should be most carefully guarded, from their birth 
up, from wounds or blows of every kind. No operation which can possibly 



ALCOHOLISM. 



DELIRIUM TREMENS. 



545 



be avoided should be performed upon them. The application of leeches 
and of blisters, the extraction of teeth and the unnecessary opening of 
abscesses, should all be avoided. Fortunately, vaccination does not seem 
to be attended with special danger. As general good health counteracts 
to a certain extent, the tendency to hemorrhage, the administration of 
iron, cod-liver oil, and other nutrient remedies between the attacks is 
recommended by almost all authors except Immermann, whose peculiar 
views in regard to the pathology of the disease have already been alluded 
to. Patients should be taught to control their passions as far as possible, 
since alarming hemorrhages have sometimes followed an ebullition of anger 
or other exciting emotion. 

The treatment during the attacks will vary with the seat of the hemor- 
rhage and, to a certain extent also, with its cause. The most effectual 
means of controlling the bleeding in those cases in which the situation 
allows its employment is pressure. It must be remembered, however, that 
this remedy is not without its disadvantages, as it sometimes causes ecchy- 
moses and even blood-tumors. It should, therefore, be carefully used. 
Styptics may also be applied to the bleeding part, and remedies, such as 
ergot, acetate of lead, and perchloride of iron, be administered internally, 
but the hemorrhage will often persist in spite of them all, and only cease 
with the life of the patient. Both Legg and Immermann hold that it is 
better not to attempt to arrest a spontaneous hemorrhage at once. It 
should be done only, in their opinion, when the patient begins to grow 
weak from the loss of blood. The ligation of an artery, in order to arrest 
a hemorrhage, should only be resorted to, if at all, in extreme cases, since 
the wound of the operation often becomes a fresh source of danger. Blood- 
tumors should, of course, never be opened. 

The affection of the joints often calls for special treatment. The pain 
is best controlled by the use of opium internally, and by soothing applica- 
tions to the part, which should be kept at rest. On the other hand, leeches 
and blisters are to be avoided, for the reason already mentioned.] 



X. CHRONIC ALCOHOLIC POISONING. {Alcoholism.) 
DELIRIUM TREMENS. 

Persons who are in the habit of drinking freely fall after a while into 
ill-health. They lose their appetite, suffer from nausea and sickness, have 
a furred tongue and offensive breath ; the limbs become tremulous and 
enfeebled, the face dull and expressionless, the conjunctivae congested and 
watery ; an eruption of acne rosacea or acne tuberculata not uncommonly 
appears upon the nose and cheeks ; they cannot sleep, become low-spirited 
and vacillating, and lose in some degree both memory and readiness or 
quickness of apprehension. They are apt to become, also, cowardly, cun- 
ning, and untruthful. Further results of drink are: cirrhosis of the liver, 
which may be followed by ascites, jaundice, or hsematemesis ; affections of 
the nervous centres, including delirium tremens, epilepsy, mania, dementia, 
and general paralysis ; and probably also gout and its various consequences. 
Drinkers (especially, it is said, those who take beer) very often grow ex- 
ceedingly fat; on the other hand they not unfrequently get much emaciated. 
Innumerable material lesions and functional disturbances are, and have 
35 



546 



DISEASES OP THE VASCULAR ORGANS. 



been, rightly attributed to the abuse of alcohol ; but there is no doubt that, 
in a very large proportion of cases, the mistake is made of attributing 
every ailment from which a drinker suffers to the influence of his drink, 
forgetful of the fact that habits of intemperance, long continued, expose 
their subject to many dangers, and to be attacked by many diseases, from 
which he would otherwise probably have escaped. 

The parts which principally suffer are the alimentary canal, liver, and 
nervous centres ; but it is to the affections of the last-named organs only 
that we now propose to direct attention. 

Nervous Disorders. Delirium Tremens. 

Causation Of affections of the nervous centres the most frequent, and 

on that account, if on no other, the most important, is that commonly 
known by the name of ' delirium tremens.' That delirium tremens, or as 
it is sometimes called delirium e potu, is a direct consequence of the abuse 
of alcohol is beyond dispute. But different views have been held in respect 
of the mode in which alcohol influences its production. It was long be- 
lieved to occur only in persons who, after drinking heavily, were suddenly 
deprived of their accustomed stimulus. More recent inquiries, however, 
show that it is more commonly the immediate consequence of excessive 
drinking, and that it usually comes on in the course of long-continued 
intemperance or of those occasional outbreaks of intemperance (lasting it 
may be for a few weeks at a time), to which some persons are liable. It 
may no doubt supervene at the time when such persons are commencing 
to abstain ; but not simply in consequence of their abstinence. 

[It is difficult, nevertheless, to explain the occurrence of delirium tre- 
mens in many cases on any other supposition than that the attack has 
been brought about by the abrupt withdrawal of stimulus. Delirium 
frequently occurs in patients addicted to the excessive use of alcohol, 
shortly after their admission to a hospital for injuries of so slight a char- 
acter that it would be unreasonable to attribute to shock any active share 
in the production of the symptoms. Moreover, the attack may often be 
averted by the administration of stimulus in moderate quantity.] 

Symptoms — The symptoms of delirium tremens creep on gradually. 
The patient loses his appetite, becomes restless and wakeful at night, his 
sleep being disturbed by frightful dreams ; he grows suspicious, inclined 
to quarrel, agitated, restless, disposed to busy himself about various mat- 
ters, and often (as Trousseau observes) to pack up his clothes and prepare 
for a journey. Generally by the time his disease has become fully estab- 
lished he has had no rest whatever for many nights, and has taken little 
or no solid food for many days. 

The symptoms of the declared affection comprise delirium with hallu- 
cinations, and tremulousness of the muscles, together with various more 
or less characteristic disturbances of the other corporeal functions. 

The face is either congested or pale. The pupils usually are dilated, 
the conjunctivae injected, the skin bathed in more or less profuse sweat. 
The tongue varies in character, but in most cases is covered with a thick 
creamy fur. There is more or less thirst, but the appetite is in complete 
abeyance. Muscular tremors are almost invariably present ; they may be 
general, or limited mainly to certain parts, such as the head and neck and 
upper extremities ; and they manifest themselves especially when the 
patient exercises his muscles, but are not necessarily absent at other 



ALCOHOLISM. DELIRIUM TREMENS. 



547 



times : — thus, the arms tremble when he holds them out, the legs when he 
stands, the lips when he speaks, and the tongue when it is protruded. 
But, besides the ordinary tremblings, there are often constant fibrillar 
twitchings of the muscles, which scarcely repeal themselves by causing 
obvious movement, but may be distinctly felt when the patient's limbs are 
grasped ; and there are often also (but more especially towards the later 
stage of the disease) involuntary startings of the limbs. The pulse varies : 
in most cases it does not, in the beginning, exceed the normal, and is then 
probably large, soft, and dicrotous ; at a later period, however, and espe- 
cially if the disease has taken an unfavorable turn, it increases in rapidity 
— rising it may be to 120 or 140, or more — and becomes at the same time 
small and extremely feeble. The temperature usually does not exceed 
101°, and often never rises to that height; but occasionally it runs up 
more or less rapidly to 105°, or even 108° or 109°. There is no relation 
between the frequency of the pulse and the elevation of temperature. The 
mental phenomena are peculiar : — The patient's sleeplessness and tendency 
to dream are soon attended with hallucinations ; he hears noises ; he sees 
black spots, or sparks, or figures ; he perceives flavors, or smells smells. 
His mind begins to wander ; he looks suspicious or frightened ; he searches 
behind the bed-curtains, under the bed, or in corners, to satisfy himself 
that there is nothing there ; he becomes garrulous — talking for the most 
part of business and of projects which he has in hand, but interrupting 
himself from time to time under the influence of some passing dread, sus- 
picion, or angry feeling. At this time he can be readily recalled to him- 
self, and will answer questions rationally and coherently. The incohe- 
rence and delirium, however, soon increase upon him. He now probably 
is incessantly chattering, talking more or less incoherently of things ab- 
sent and things present, but still with a marked tendency, as a rule, to 
dwell upon matters of business, to give orders to his servants or work- 
people, to talk with customers. He suffers, also, from manifest illusions ; 
he not only has singing and other noises in his ears, but he hears voices, 
and it may be enters into conversation with them ; he not only sees muscse, 
but he takes them (according to their characters) to be insects, or sparks, 
or coins, and he may be seen consequently endeavoring either to catch the 
animals which infest him, or to pick up the silver which is strewed around 
him ; or he fancies that he sees larger objects, dogs or cats, strange per- 
sons or devils, and watches them as they slip behind some article of furni- 
ture, or peep at him from some obscure corner. In many cases his illu- 
sions are wholly of a nature to inspire horror or terror ; policemen are after 
him for some murder he has committed ; he is haunted by bad spirits ; 
foul reptiles are crawling about him ; great disasters threaten or have 
already involved his dearest friends. In some cases they are pleasing or 
funny ; he is surrounded by beautiful scenery, he hears sweet music, he 
sees dancing girls or acrobats performing the most extraordinary feats. 
In some cases again he becomes wildly maniacal ; in some sullen, morose, 
and stupid. He is apt also to mistake those about him for persons who 
are absent, or to confound them with the grotesque or horrible creations 
of his mind. His actions are no doubt in relation with the thoughts or 
fancies which are passing through his brain ; he will often, as above pointed 
out, be seen busily picking up insects, flowers, or coins which are crawling 
or falling about him ; or he will sit up and look suspiciously around ; or 
he will endeavor to rise from his bed and will hunt everywhere for imagi- 
nary objects ; or he will strive to avoid some danger or some foe, or will 



548 



DISEASES OF THE VASCULAR ORGANS. 



attack his attendant in the belief that he is contemplating or perpetrating 
some injury against him or his friends ; or he will perform various gro- 
tesque acts, such as climbing up the bed-post, standing on his head, or 
turning head over heels, or will applaud by shouts or laughter some im- 
aginary performance. But in all cases, even though he has well-marked 
dominant illusions or frames of mind, there is a remarkable changeable- 
ness in his illusions and moods ; he passes momentarily from one thing to 
another, and is suspicious, cowardly, violent, and merry in rapid succes- 
sion ; and in all cases, or nearly all, he can be recalled momentarily to 
himself, and restrained, by the voice of authority. Epileptiform attacks 
occasionally come on in the course of the disease. 

In most cases, delirium tremens terminates favorably ; and at the end 
of three or four days, or i.t may be a week, from the commencement of his 
malady, the patient falls into a gentle sleep and awakes refreshed and con- 
valescent. But occasionally (and in those persons whose habits insure 
frequent recurrences, necessarily at length) the attack ends fatally by coma 
or asthenia. The circumstances which, according to M. Magnan, foretell a 
fatal issue, are elevation of temperature, persistent muscular agitation, and 
muscular debility or paresis. If the temperature rises to 102° or 103° 
(even though other symptoms appear favorable) there is ground for alarm ; 
if, after continuing at this elevation for a day or two, it suddenly rises 
above 104°, the danger becomes very great and in some degree propor- 
tionate to the amount of the rise. As regards muscular tremors, it is not 
so much their intensity as their general prevalence and persistence which 
should excite alarm. They are especially of ill omen when they continue 
during sleep, and when to the general muscular vibration is superadded 
subsultus tendinum. Great rapidity and extreme feebleness of pulse, epi- 
leptic convulsions, coma, and the formation of bed-sores point also to a 
fatal termination. 

The subject of delirium tremens must not be dismissed without drawing 
attention to the fact that in persons who are habitual drinkers, it not 
unfrequently happens that other illnesses (acute or chronic) which attack 
them become complicated with some of the symptoms of delirium tremens. 
Thus it is with serious accidents, pneumonia, and other inflammatory and 
febrile disorders ; and thus, also, it not uncommonly is with hysteria. 
Nor must it be-forgotten that delirium tremens is apt to be closely simu- 
lated by various affections, and more especially by meningitis and acute 
inflammations. 

Other consequences of drink are epilepsy, insanity in its various forms, 
general paralysis, and dementia. These, however, are not special to al- 
coholism, and need not now detain us. Dr. Wilks has specially drawn 
attention to a form of incomplete paraplegia — attended sometimes with 
inco-ordination, sometimes with anaesthesia, and often with more or less 
pain in the limbs, and involving sometimes the legs only, sometimes the 
legs and arms — due to alcoholism, but immediately dependent, he thinks, 
on chronic spinal meningitis. It appears generally to be curable by ab- 
stinence. 

Pathology and morbid anatomy Alcohol taken into the stomach is 

rapidly absorbed. It is eliminated, but apparently in very minute quan- 
tity, by the kidneys, lungs, and skin ; yet it disappears quickly from the 
system. Generally, even if large quantities have been imbibed, none can 
be detected by chemical analysis after the third or fourth day ; but Dr. 
Dupre believes that ten days may be taken as the period needed for its 



ALCOHOLISM. DELIRIUM TREMENS. 



549 



entire discharge. It is obvious, therefore, that the great bulk must undergo 
chemical decomposition in the interior of the body. Alcohol may be found 
post mortem in various organs ; it has been discovered in the liver, but is 
much more readily detected in the brain, for which it seems to have a 
special affinity. The conditions of the stomach, intestines, and liver which 
supervene upon chronic alcoholic poisoning, are elsewhere described. The 
post-mortem appearances presented by the central nervous organs are not 
very striking ; in those who have been long given to drink, the brain is 
often found to be somewhat shrunken, the subarachnoid tissue opaque, and 
its proper fluid in excess ; but in those who die of delirium tremens, there 
is usually more or less marked congestion of the cortex and medulla of the 
brain and of the upper part of the spinal cord. Moreover, there is not un- 
frequently discovered a deposit of refractive granules, and even of haema- 
toidine crystals in the walls of the small vessels. There is no reason to 
believe that other tissues or organs suffer in any important degree. Dr. 
Dickinson has shown that there are no sufficient grounds for referring 
chronic renal disease to the effects of alcohol. 

Treatment Our remarks under this head will have reference solely to 

delirium tremens. It is impossible to reconcile the different views that are 
held with respect to the treatment of this disorder. Formerly it was held, 
and by physicians of high eminence and large practical experience, that 
the one thing needful was to give the patient sleep. But now Drs. Lay- 
cock, Gairdner, Wilks, Anstie, and many others, urge that the disease is 
one of low mortality, which tends to get well of itself within a limited 
time, and that not only is opium not needed, but that its use is attended 
with no inconsiderable danger. The patient has been without food, or 
almost without food, for a considerable length of time ; and they strongly 
urge that he should be fed with such nourishment as he can be made to 
take, and that it is by nourishment mainly that he is to be successfully 
treated. We do not deny that many of these cases do tend to recovery, 
and that feeding is an essential point in their treatment; but we cannot 
help thinking that more power for harm, and less power for good, than it 
deserves, have latterly been attributed to opium. We think, too, that 
opiates may be given with more benefit and less danger in inflammatory 
and other lesions of the brain than is generally suspected. A person suf- 
fering from delirium tremens should be separated from other patients; the 
room in which he is placed should be kept absolutely quiet, and the bright 
light of day excluded. Everything, indeed, around him should tend to 
quietude and to solicit sleep. He should be constantly watched by a trust- 
worthy and competent attendant. Under these circumstances it is not 
generally requisite to employ mechanical restraint ; yet sometimes it be- 
comes absolutely necessary to tie him down with a sheet or band, or to 
fasten his hands and feet to the bed with gauntlets. Nutriment should be 
administered with careful attention in small quantities and frequently. 
The most appropriate articles of food are milk, arrowroot, beef-tea, broths, 
and eggs. The bowels should be regulated. Those who consider sleep 
indispensable would now administer either chloral or some preparation 
of opium. The chloral is sometimes given with advantage in doses of 
from ten to twenty grains every half-hour until sleep is induced. Opium 
or morphia may also be given in comparatively small doses at short inter- 
vals. It is better, however, we believe, to administer it from the begin- 
ning in large doses, and to repeat it or not according to its effect ; to give, 
for example, from half a grain to a grain of morphia, or from half a drachm 



550 



DISEASES OF THE VASCULAR ORGANS. 



to a drachm of laudanum at once, and to repeat the medicine in smaller 
doses at intervals of an hour or two, if sleep be not induced. So also with 
respect to chloral, we believe it better to give a large dose at once, say 
sixty or eighty grains, and to supplement this with subsequent smaller 
doses, if needful. If, as is doubtless best, the morphia be given by subcu- 
taneous injection, the dose must be reduced to one-sixth or one-third of a 
grain. It may be well to add that patients with delirium tremens are dif- 
ficult to bring under the influence of narcotics. Other remedies which 
have had, or have, strong advocates, are: digitalis in large doses (half an 
ounce to an ounce of the tincture) ; cayenne pepper; and bromide of po- 
tassium in doses of from ten to thirty grains. It is sometimes advisable 
to give the patient some of the alcoholic stimulus to which he has been 
addicted. When he is convalescent, quinine or other tonics are indicated, 
and he should, as far as possible, be debarred from drink. The proba- 
bility, however, is that he will, so soon as opportunity offers, resume his 
evil habits. 



XI. CHRONIC LEAD-POISONING. {Plumbism.) COLIC. 
DROPPED HAND. 

Causation When lead, in even minute quantities, is habitually intro- 
duced into the system, characteristic and more or less serious consequences 
are pretty certain to ensue sooner or later. In most such cases the poison- 
ing is very insidious, and not unfrequently its source is only discovered 
after patient research or by accident. Plumbism was formerly largely 
prevalent : in Poictou, in consequence of the habitual addition of lead to 
inferior qualities of wine ; in the West Indies, owing to the fact that 
leaden worms were used in the stills employed in the manufacture of rum ; 
in Devonshire, as a result of the general employment of lead in the con- 
struction of the vessels used in making cider ; and both in our own country 
and elsewhere, from the storage of drinking-water in leaden cisterns, or 
its conveyance through leaden pipes. In all these cases, the fluid, acting 
chemically upon the lead, and rendering it soluble, became in a greater or 
less degree impregnated with it. It is worth while to draw attention to 
the fact that rain-water and other soft waters become much more readily 
impregnated with lead than hard waters, provided these latter contain 
sulphate and carbonate of lime, and not too large a proportion of alkaline 
chlorides or nitrates. At the present day the contamination of drinking- 
water with lead is comparatively rare ; and the chief source of lead- 
poisoning is the employment of this metal in manufacture and trade. To 
quote the words of Dr. Taylor, ' The carbonate' (to which salt chronic 
poisoning is usually attributable) ' finds its way into the system, among 
white-lead manufacturers, either through the skin or through the lungs, or 
both together ; it is diffused through the air as a fine dust, and is not only 
respired, but taken into the mouth and swallowed with the saliva. It has 
been remarked that in factories where the powder was ground in a dry 
state, not only have the laborers suffered, but horses, dogs, and even rats 
have died from its effects. Since the practice has arisen N of grinding the 
white lead in water, cases of colica pictonum have not been so numerous. 
They are still, however, not unfrequent among painters, plumbers, pew- 



CHRONIC LEAD -POISONING. 



551 



terers, the manufacturers of some kinds of glazed cards, the bleachers of 
Brussels lace, and among those engaged in the glazing of pottery, where 
oxide of lead is employed in the glaze.' " The workers in metals — plumbers 
who handle metallic lead — are but little subject to the disease.' Amongst 
rare but well-ascertained causes of lead-poisoning are the employment of 
lead medicinally, its application to ulcerated surfaces (Althaus), the use of 
snuff impregnated with lead (Hassall and Garrod), and sleeping in a 
newly-painted-room. [The application of lead, either alone or diluted 
with an inert powder, to the face and neck as a cosmetic, even when the 
skin is entirely unbroken, has also been followed by well-marked symp- 
toms of poisoning.] Some persons present the symptoms of plumbism 
who have been exposed in a very slight degree to the poison, who have 
taken, it may be, only a dose or two of lead medicinally ; while others 
(painters for example) may go on with their work for twenty years or more, 
and yet escape. 

Symptoms and Progress.— Those who are under the influence of the 
chronic operation of lead often suffer more or less in their general health ; 
their complexion is said to get sallow and earthy-looking, their skin dry 
and harsh ; they become thirsty, lose appetite, and have a sweetish or 
metallic taste in the mouth. Dr. Garrod points out a remarkable connec- 
tion between gout and plumbism, shown by the circumstance that a very 
large proportion (one-fourth) of his hospital gouty patients had suffered 
from lead-poisoning. And, indeed, whether that connection be accidental, 
or due to the fact that lead-poisoning predisposes to gout, or that constitu- 
tions liable to gout are also peculiarly susceptible of the influence of lead, 
general experience seems to confirm the accuracy of Dr. Garrod's obser- 
vation. Chronic albuminuria is also not unfrequently associated with lead 
poisoning. A curious effect of lead was discovered some years ago by Dr. 
Burton which is of great importance from a diagnostic point of view : 
namely, the formation of a blue line along the edges of the gums immedi- 
ately adjoining the teeth. This is situated in the substance of the gum, 
but appears to be largely determined by the amount of tartar present, and 
is supposed to be due to the precipitation of the lead, in the form of the 
sulphide, by the sulphuretted hydrogen emitted by the decomposing mat- 
ters which are mingled with the tartar. This blue line is not, however, 
an infallible sign of lead-poisoning ; for it occasionally gets developed in 
the course of a few hours after the use of two or three medicinal doses of 
lead ; it is generally present in lead workers who are free from all other 
symptoms ; it often remains long after all possibility of poisoning has 
passed away ; it is sometimes absent from cases of undoubted plumbism ; 
and further, it may be caused by cuprous and other varieties of metallic 
impregnation. It is said that a similar blue line may be detected at the 
verge of the anus, and at the margins of ulcers. By far the most import- 
ant consequences of lead-poisoning, however, are colic, and certain affec- 
tions (mainly paralytic) of the nervous system. Of these colic is the more 
common, and, when the two conditions coexist or alternate, is usually the 
earlier in making its appearance. 

A. Lead colic is characterized by the more or less gradual supervention 
of severe griping pains, attended with obstinate constipation and vomiting. 
The pains differ in no respect from those which follow upon impermeable 
intestinal stricture, and apparently are due to the same cause — namely, 
the powerful contraction, frequently repeated, of certain lengths of bowel 
above, in order to overcome some impediment to the passage of their con- 



552 



DISEASES OF THE VASCULAR ORGANS. 



tents into and through the length of bowel immediately following. They 
are referred mainly, as such pains usually are, to the umbilical region, 
come on at intervals with extreme severity, and, when the disease is fully 
established, are associated with more or less intense inter-paroxysmal un- 
easiness or pain. The pain is not generally aggravated by pressure, and 
indeed is often relieved both by that means and by friction. The parox- 
ysms are attended with more or less obvious peristaltic movement of the 
bowels, and borborygmi. Vomiting may arise early from sympathy or 
late from the direct influence of obstruction. The abdominal walls are 
usually retracted, and the muscles hard and tense. Colic rarely proves 
fatal ; but might readily become fatal if the cause to which it is referable 
should continue in operation. Its duration varies ; it may last for a day or 
two only, or be continued for a week, or, with remissions, for a still longer 
period. Moreover, when once there has been an attack there is great 
liability to recurrence. It is rarely if ever attended with fever or intesti- 
nal inflammation. 

B. Nervous disorders. Dropped hand — Of nervous disorders, dropped 
hand, from paralysis of the extensors of the forearm, is by far the most 
frequent ; but sometimes the paralysis is of much more general distribu- 
tion. Dropped hand generally comes on consecutively to colic, sometimes 
gradually, sometimes more or less suddenly. In some cases one hand only 
is affected, and this is usually the right ; but more frequently both hands 
are implicated, though in unequal degrees. The more obvious symptoms 
of the affection are loss of power over the extensor muscles of the fore- 
arm, in consequence of which the patient is unable to extend the hand 
upon the arm, or the first phalanges of the fingers upon the metacarpal 
bones, to adduct or abduct the hand, or to abduct the thumb. The hand 
consequently drops when the arm is held out prone, and both the hand 
and the first joints of the fingers are more or less powerfully flexed in 
consequence of the predominant action of the flexor muscles. The para- 
lyzed muscles waste rapidly, so that a distinct hollow is apt ere long to 
manifest itself between the bones at the back of the forearm ; and more- 
over, while retaining their electro-sensibility, they lose more or less com- 
pletely their faradic contractility. The remaining muscles of the forearm, 
and even those of the upper arm, are apt to get enfeebled, though not 
otherwise affected. There is no impairment of cutaneous sensibility; but 
it not unfrequently happens that more or less severe pain and tenderness 
in the situation of the affected muscles attend the acute stage of the affec- 
tion. 

It is an important fact that the paralysis is limited, as a rule, to muscles 
supplied by the musculo-spiral nerve, and mainly to those supplied by its 
posterior interosseous branch. Those which usually suffer are the follow- 
ing, enumerated in the order in which (according to Duchenne) they are 
liable to be attacked : — extensor communis digitorum, extensor indicis, 
extensor minimi digiti, extensor secundi internodii pollicis, extensor carpi 
radialis brevior, extensor carpi radialis longior, extensor carpi ulnaris, 
extensor ossis metacarpi pollicis, and extensor primi internodii pollicis. 
Occasionally also the muscles of the ball of the thumb suffer. But the 
supinators, the muscles of the front of the forearm, and those of the hand 
(with the exceptions which have been pointed out), although they may 
get enfeebled, seem never to become distinctly paralyzed, to lose their 
faradic contractility, or to waste. It must be borne in mind, however, 
that the muscles are not necessarily involved in the order above named, 



CHRONIC LEAD - POISONING. 



553 



and that they do not necessarily all suffer in every case. Tf the extensor 
communis be alone affected, the middle and ring fingers alone drop, the 
index and little finger retaining the power of extension, though somewhat 
enfeebled ; if the extensores indicis and minimi digiti also suffer, all four 
fingers are implicated ; if the radial and ulnar extensors of the carpus be 
paralyzed, the wrist falls ; if the radial or ulnar alone, then the patient in 
endeavoring to extend the hand tilts it towards the opposite side ; if the 
muscles of the thumb be implicated, the thumb lies in front of the hand 
in the position of opposition. The power of supination and that of pro- 
nation remain intact ; and provided the first phalanges be supported in 
the extended posture, the second and third phalanges may always be vol- 
untarily extended, a fact confirming the integrity of the interossei muscles. 

In some instances the paralysis, loss of faradic contractility, and wast- 
ing involve other muscles of (he upper extremity besides those of the fore- 
arm. Those which are then chiefly liable to suffer are the deltoid and 
triceps. In some cases the paralysis is limited to the deltoid. Occasionally, 
again, lead-palsy involves the muscles of lower extremities, selecting espe- 
cially the extensors of the foot upon the leg, and of the leg upon the thigh ; 
or the intercostal muscles ; or the diaphragm. And in some very rare 
cases, of which Duchenne quotes a striking example, paralysis attacks 
with more or less suddenness nearly all the voluntary muscles. 

The duration of saturnine paralysis is very various ; it may be weeks, 
months, or years. Moreover, the paralysis, like the colic, is apt to recur. 
The longer it has been in existence, the less, as a rule, is the prospect of 
ultimate recovery ; and further, extreme wasting of the muscles, and per- 
sistent abeyance of faradic contractility, are also of bad augury. Yet 
Duchenne draws attention to the interesting fact that in these cases volun- 
tary power may occasionally be recovered, even though the muscles remain 
irresponsive to faradic excitation. 

Epileptic attacks sometimes come on in the course of lead-poisoning, 
and other cerebral phenomena, including coma. 

Pathology and morbid anatomy — After lead has been received into the 
organism, it is deposited in various parts, and discharged by various 
emunctories. It has been found post mortem in the spleen, liver, lungs, 
kidneys, heart, and intestinal walls, and also in the substance of the brain 
and in the muscles. It passes off mainly with the urine ; but, according 
to Dr. Pereira and others, there is some elimination by the skin ; and Dr. 
Taylor states that it has been found in the milk. It is apt to remain in 
the tissues for some time, and has been detected in them by M. L. Orfila 
as long as eight months after its reception has been discontinued. The 
appearances found after death from chronic poisoning are for the most part 
very indecisive. After death from colic, or in cases in which colic has 
been present, the bowels (especially the large intestines) are said to be 
generally contracted and empty, or to present alternate contractions and 
dilatations, or intussusceptions ; occasionally, also, spots of congestion have 
been seen in the mucous membrane. These are changes, however, which 
may be observed in many cases besides those of lead-poisoning. The 
paralyzed muscles, as has been already stated, shrink rapidly and to an 
extreme degree ; and post mortem are often observed to be remarkably 
pale and yellowish. But, on microscopic examination, their tissue is 
usually found to present a perfectly normal appearance. It is only after 
paralysis has existed for many years that degenerative changes get added 
to simple atrophy. The fibres sometimes become fatty. Whether the 



554 



DISEASES OF THE VASCULAR ORGANS. 



intestines are affected through the nervous system, or by the presence of 
lead in their walls, may be a subject of doubt. But, as regards the paral- 
ysis of the voluntary muscles, there is no doubt that Duchenne is right in 
regarding it as a consequence of nervous disorder. For if it were mus- 
cular, not only should we find the muscular fibres degenerated in proportion 
to their loss of power, but we should find faradic contractility surviving 
as long as any healthy muscle was left. On the other hand, the rapid 
shrinking of the muscles, without degeneration, and their speedy loss of 
faradic contractility, obviously point to lesion either of the nerve-trunks 
or of their nuclei of origin. 

Treatment Whenever a case of lead-poisoning comes under treatment 

a careful inquiry should be made into the probable source of contamination, 
with the object of removing or counteracting it, or of putting the patient 
upon his guard. It is obvious that it would be well for patients whose 
occupation exposes them to the danger of continued lead-poisoning, to 
seek some other employment. But this they will rarely consent to ; and, 
indeed, it is often impossible for them to do it. Apart from the question 
of the improvement of processes of manufacture in order to minimize the 
risks of those employed (a subject upon which we do not presume to enter) 
it may be mentioned : that extreme personal cleanliness is important for 
all those who are exposed to danger ; and that there are good grounds for 
believing that the habitual use of lemonade made with sulphuric acid is to 
a considerable extent protective, by converting the carbonate or other 
salts of lead in the stomach into the insoluble and inert sulphate. 

Various methods of treatment have been suggested with the object of 
removing lead from the system — the more important of them being the 
employment of baths containing some soluble sulphide, and the internal 
use of iodide of potassium. Dr. Pereira recommends baths medicated with 
sulphide of potassium, in the proportion of two ounces to fifteen gallons, in 
the belief that the lead escaping from the surface of the skin would thereby 
be converted into insoluble sulphide. .This result does in fact happen ; 
but there is no reason whatever for suspecting that the baths promote the 
escape of lead in any important degree. M. Melsens suggested the em^ 
ployment of iodide of potassium, on the ground that the iodide makes, 
with the insoluble salts of lead deposited in the tissues, a soluble double 
salt capable of removaLby the kidneys. This practice is commonly followed. 

In the treatment of lead-colic it is best, we believe, to relieve pain and 
discomfort by opiates and fomentations, and to leave the bowels to act of 
themselves, as they will usually do at the end of a few days. If it be 
thought right to remove the contents of the lower bowel, this may be 
effected by means of copious enemata of warm water or warm gruel. 
Many, however, prefer the course which Sir Thomas Watson advocates : 
namely, the exhibition of a full dose of calomel and opium — ten grains of 
the former with two of the latter — which he says usually soothes the vomit- 
ing, restlessness, and pain, and may be followed up successfully by a dose 
of neutral salts or castor oil. Alum, in doses of a scruple or half a drachm 
three times a day, has been highly recommended. 

For the restoration of the paralyzed and wasting muscles, galvanism is 
the only effectual remedy. Faradization is employed by M. Duchenne, 
who recommends that a powerful current should be used three times a week 
for as long a period as may be necessary — it may be as much as two or 
three months. Each sitting may last for ten or fifteen minutes. He recom- 
mends also that each muscle should be separately galvanized. The slowly 
interrupted constant current, similarly employed, is even more efficacious. 



CHRONIC MERCURIAL POISONING. 



555 



XII. CHRONIC MERCURIAL POISONING. (Mercurialism.) 

Causation. — Chronic mercurial poisoning may result from the long-con- 
tinued medicinal use of any of the preparations of mercury ; but it is most 
frequently due to habitual exposure to the vapor or dust of mercury, or its 
salts, which certain manufactures or trades involve. Those, therefore, 
who chiefly suffer are the workmen engaged in quicksilver mines ; water- 
gilders ; the manufacturers of looking-glasses, barometers, and thermome- 
ters ; furriers, and those engaged in the packing of furs which have been 
brushed over with solution of nitrate of mercury. 

Symptoms and progress. — The symptoms of chronic mercurial poison- 
ing have reference mainly to the nervous and muscular systems, and are 
commonly included under the term ' metallic tremor.' The first indica- 
tions of this condition are : a general tremulousness of the hands and arms, 
coming on for the most part gradually ; slight numbness or tingling in the 
hands or feet ; and occasional pains in certain joints, more especially those 
of the thumbs, elbows, feet, and knees. Tremors are common amongst work- 
people exposed to the vapor of mercury, and may continue for years without 
materially interfering with their capacity for work or their general health. 
But sooner or later they tend to get aggravated ; they not only become 
more violent, but gradually extend to all parts of the muscular system ; so 
that they involve at length the hands, arms, and legs, the head and neck, 
including the muscles of expression, speech, and deglutition, and the trunk 
with the muscles of respiration. Then the violent trembling of the hands 
and arms renders the patient more or less incapable of using them for any 
purpose, especially for delicate operations — he probably cannot lift a glass of 
water to his lips, or feed or dress himself ; the agitation of his legs gives 
to his attempts to walk or stand a peculiar jerkiness or choreic character, 
and, indeed, before long he is probably unable to stand or walk without 
support ; the convulsive action of the muscles of his head and neck causes 
constant tremulous movements of these parts, while that of the muscles of 
expression reveals itself in grimaces, and that of the lips, tongue, and mus- 
cles of mastication causes tremulous, indistinct and divided utterance, and 
difficulty of mastication ; the involvement of the respiratory muscles in- 
duces more or less difficulty of breathing. All these convulsive movements 
are usually in abeyance when the patient is lying down and making no 
muscular effort ; but they reveal themselves whenever he attempts volun- 
tary movement, and become especially aggravated w T henever he is under 
observation. Further, the patient is liable to occasional, apparently cause- 
less, exacerbations of more or less severity. At a very advanced period of 
the disease, the convulsions do not wholly cease when the patient is in bed ; 
and then occasionally continue also during sleep. Moreover, they are now 
not unfrequently associated with sharp pains in the limbs, and occasional 
attacks of tonic contraction. It would seem, and the point is an important 
one, that the muscles or the eyeballs do not share in the convulsive move- 
ments, and that there is an absence of nystagmus. There is no real loss 
of sensation. 

The symptoms above enumerated are not necessarily associated with 
any other indications of mercurial poisoning or signs of ill-health. But in 
a considerable number of cases the patients either have previously suffered 
from salivation and ulceration of the gums, fetid breath, nausea, sickness, 
colicky pains, disturbance of the bowels, and fever ; or present these phe- 



556 



DISEASES OF THE VASCULAR ORGANS. 



nomena in a more or less marked form at the time when the nervous symp- 
toms supervene ; or begin to suffer from them during the course of the 
tremors, even if they have never thus suffered previously. And generally, 
after the tremors have attained a high degree of severity, cachectic symp- 
toms come on ; the patient gets sallow, emaciated, and weak ; he loses 
his appetite ; and there is more or less general failure of his circulatory 
and other functions. Sometimes, also, various cerebral complications are 
developed, such as vertigo, headache, loss of memory, delirium, epilepsy, 
paralysis, or coma. 

Chronic mercurialism is not generally a fatal or even dangerous disease; 
mainly, however, for the reason that those who are affected with it are 
usually compelled to give up their employment, and thus escape further 
risk. But for such as continue to expose themselves to the vapor of mer- 
cury, the prospect of early death is by no means uncertain — death under such 
circumstances being caused, either by extreme debility, or by some of the 
ordinary effects of mercury on the gums and mouth, or intestinal canal, 
or by some cerebral complication, or by the supervention of intercurrent 
disorders. 

The affections with which mercurial tremors are most likely to be con- 
founded are disseminated sclerosis, and paralysis agitans. But careful 
attention to the history and details of symptoms will generally enable an 
accurate differential diagnosis to be made between them. It may, how- 
ever, be worth while to point out, as practical hints, that paralysis agitans 
does not commonly affect the muscles of the head and neck, but imparts 
to the patient a tendency to run forwards, and that generally in dissemi- 
nated sclerosis there is well-marked nystagmus. 

Morbid anatomy. — No characteristic lesions have been discovered in 
the internal organs of patients who have died of chronic mercurialism. 
But mercury has been detected chemically in various parts of the body, 
more especially the brain, liver, and kidneys. 

Treatment The preventive treatment of mercurial poisoning includes 

the taking of measures to guard against the entry of mercury into the 
system, either by adopting such modifications of the processes of manu- 
facture as minimize the diffusion of the poison through the atmosphere, or 
by compelling the workers to Avear respirators or other protective cover- 
ings to the face, to wash their hands before eating, and to change their 
clothes and wash after leaving work. The direct treatment of chronic 
mercurialism by drugs is of little use. It may on the whole be judicious 
to act on the bowels, kidneys, and skin, for the purpose of promoting the 
discharge of the poison. It may even be well to adopt the treatment 
already suggested for chronic lead-poisoning, namely, the administration 
of iodide of potassium, with the object of combining the mercury in the 
system therewith into a soluble double salt. But the essential part of the 
treatment, and that w T hich is alone of real efficacy, is the removal of the 
patient from the influence of mercury. Excepting in cases of extreme 
severity or long duration, restoration to health is thus effected in the course 
of a few weeks or months. Tonics may often be given with advantage to 
the patient's general health ; and galvanism may be applied with benefit 
to the enfeebled muscles. 



CATARRH. 



557 



CHAPTEK Y. 

DISEASES OF THE DIGESTIVE ORGANS. 

Section I. — DISEASES OF THE MOUTH, FAUCES, AND 
ADJACENT PARTS. 

I. CATARRH. 

Causation The most common, and on the whole perhaps the most im- 
portant, variety of inflammation affecting the mouth, fauces, and parts in 
relation with them is that which results from exposure to cold, and gives 
rise to the phenomena which collectively constitute what is commonly 
known as a ' cold' or catarrh. 

Morbid anatomy. — Catarrhal inflammation commences with hyperemia, 
infiltration, and tumefaction of the affected mucous tissue, diminution of 
the secretions from its surface, and from the glands which open upon it, 
and consequent abnormal dryness. Before long, however, the inflamed 
parts begin to pour out a thin, watery, somewhat acrid discharge, in con- 
siderable abundance ; and at the same time the tumefaction usually under- 
goes some diminution. Subsequently the secretion gets thick, opaque, and 
yellowish or greenish, and assumes the characters of muco-pus or pus. 
This change generally indicates the commencement of the end ; for now, 
if nothing occurs to interfere with the normal progress of the case, the 
tumefaction and secretion both gradually subside, and the mucous mem- 
brane returns to its healthy state. Catarrhal inflammation does not, as a 
rule, seize at once on any extensive tract, but rather, like erysipelas, 
begins in a comparatively small area, whence it spreads. Nor does it, 
even in the case of any one who is liable to it, always commence in the 
same spot. Thus it often, perhaps most frequently, begins in the mucous 
membrane of the nose, whence it spreads by continuity to the fauces, and 
thence to the larynx and probably to the trachea and bronchial tubes ; or 
it first manifests itself in the larynx, whence it extends upwards into the 
nose, and downwards into the chest ; or it first attacks the fauces, soft 
palate, or it may be the gums. The regions which are liable to be involved 
in the course of catarrh, and in any one of which probably it may com- 
mence — thence extending to the others — are the following : the nose and 
sinuses in relation with it, with the lachrymal ducts and conjunctivae ; the 
fauces and pharynx, together with the Eustachian tubes and tympanic 
cavities, and the oesophagus ; the oral cavity, including the palate, gums, 
sockets of the teeth, and tongue ; the periosteum of the facial bones, and 
branches of the fifth pair ; and, lastly, the larynx and subordinate respira- 
tory passages. 

Symptoms and progress The symptoms of a cold necessarily differ 

according to the regions which mainly suffer. The special symptoms, 



558 



DISEASES OF THE DIGESTIVE ORGANS. 



however, are always associated with the ordinary phenomena of febrile 
disturbance. The latter vary in severity, but are generally mild — some- 
times scarcely noticeable — and always most severe during the first day 
or two of the attack. They comprise elevation of temperature, heat and 
dryness of skin, alternating with perspirations which come on mainly at 
night-time, increased frequency of pulse, thirst, constipation, scanty urine 
with abundant uratic deposit, muscular pains, and frequently drowsiness. 
The febrile symptoms are sometimes alarming in the case of young 
children. 

The symptoms of catarrh affecting the cavity of the nose are, in the 
first instance, dryness, obstruction and irritability of the nasal passages, 
associated with frequent paroxysms of sneezing, the performance of respi- 
ration mainly through the open mouth, and inability to pronounce the 
nasal consonants, m, n, and ng. To these succeeds more or less copious 
defluxion of thin watery mucus, which frets the margins of the nostrils 
and the upper lip. There is probably still great irritability of the mucous 
surface, with paroxysmal sneezing ; but with the continuance of the dis- 
charge the nasal passages become more pervious, and the symptoms due 
to obstruction to some extent subside. Finally, the discharge gets thick, 
and, at the same time, less abundant, the tumefaction and irritability of 
the mucous membrane diminish, and convalescence ensues. Associated 
with nasal catarrh, there is always more or less complete loss of smell, 
especially during the earlier stages ; and, probably owing to implication of 
the frontal sinuses, there is often severe headache, limited to the situation 
which the sinuses occupy, and not unfrequently attended with drowsiness. 
The extension of inflammation to the conjunctivae is shown partly by 
obstruction of the lachrymal ducts, in consequence of which the tears 
are compelled to flow over the face, partly by the supervention of oph- 
thalmia. 

The indications of catarrhal inflammation of the fauces are, unnatural 
redness of the soft palate and pillars of the fauces, and, in a greater or less 
degree, of the contiguous mucous surfaces ; together with tumefaction of 
the same parts, but more particularly perhaps of the lax tissue of the 
uvula, which is apt to become oedematous and enlarged in all its dimen- 
sions. The first symptoms of which the patient complains are dryness, 
stiffness, and itching or tingling, commencing at one side, or in some de- 
fined area, but soon becoming more or less general throughout the fauces 
and soft palate, and frequent tendency to swallow in order to relieve the 
uncomfortable feeling in the throat, to clear the throat, and to cough a 
slight hacking cough. The act of deglutition is more or less painful. With 
the supervention of the stage of secretion, the efforts to swallow and clear 
the throat get more effective and less painful, the patient becomes compara- 
tively comfortable, and convalescence soon follows. Involvement of the 
Eustachian tube and ear is indicated, first by itching or shooting pains in 
the course of the tube and in the ear, then by deafness, and the usual signs 
of aural inflammation. Extension of catarrh along the oesophagus to the 
stomach is rarely, if ever, manifested by prominent symptoms. Those 
usually observable are a sensation of warmth along the oesophagus and in 
the stomach, and slight dyspeptic symptoms, more especially frequent eruc- 
tations and craving for food. 

Catarrhal inflammation of the mouth more frequently and seriously af- 
fects those who suffer from bad teeth than those whose teeth are sound, and 
reveals itself mainly by pain, tenderness, and swelling of the gums, and 



CATARRH. 



559 



particularly of the periosteum of the sockets of the teeth. The teeth con- 
sequently become loose and tender; and neuralgic pains, often most severe 
at night-time, flicker about the gums, and sometimes extend to the perios- 
teum of the jaws, and along the superficial branches of the fifth pair. 

Catarrhal inflammation of the larynx is elsewhere described under 
the name of laryngitis, and that of the bronchial tubes under the name of 
bronchitis. 

It remains to say that catarrh, in the sense in which the word is em- 
ployed in 'the present article, is an affection of very various importance. 
In the majority of cases it must be regarded as a trivial disorder, which 
reaches its full development in the course of a day or two, and lasts at the 
outside, not more than a week or ten days. Yet, without attaining any 
special severity, it may be kept up for an almost indefinite period if the 
patient continue to expose himself to its exciting cause. Nor can it be 
regarded as entirely devoid of danger, especially if it involve the larynx 
or bronchial tubes ; for, although in many cases the laryngeal or bronchial 
affection is really slight, it differs only in degree from the severest forms 
of primary laryngitis or bronchitis, and may readily pass into one or other 
of them. Further, although the pain and discomfort of catarrh are com- 
monly neither severe nor of long duration, there are exceptions to both of 
these rules. The chief exceptions are furnished by those cases in which 
the inflammation spreads to the teeth, periosteum, and branches of the fifth 
pair, and those in which it attacks the ear — in both of which cases the pain 
is often intense, and continues may be, with little intermission, for weeks 
or months. 

Treatment Trivial as a common cold may seem to be, it is yet of such 

frequent occurrence, and a source of so much discomfort, especially to 
those who are liable to its attacks, that its treatment cannot be regarded 
as unimportant. As a general rule, patients suffering from cold should 
confine themselves to a warm and well-ventilated but not draughty room ; 
and should, if not in bed, be warmly clad. A hot bath — water, vapor, or 
air — should be taken before going to bed, together with some warm drink, 
and a little Dover's powder — measures which are serviceable in relieving 
pain and discomfort, in promoting sleep, and in exciting perspiration. 
During the day, the occasional inhalation of steam is often very useful, as also 
are frequently repeated small doses of ipecacuanha and opium, either in the 
form of Dover'js powder, or associated with some febrifuge mixture, or with 
ether or ammonia. Sir T. Watson notices with especial approval the 
treatment of a commencing catarrh with (in the adult) about twenty 
minims of laudanum at one dose, or with about half that quantity of lau- 
danum combined with seven or eight minims of vinum antimoniale, re- 
peated every third or fourth hour for three or four times ; as also Sir Henry 
Halford's practice (which accords pretty nearly with the usual domestic 
routine) of giving at bed-time a beaker of hot wine negus with a table- 
spoonful of the syrup of poppies. He also observes that there is ' a period 
in catarrh which has gone on unchecked when you may accelerate its de- 
parture by a good dinner and an extra glass or two of wine.' Counter- 
irritation is .sometimes serviceable ; and if the fauces or larynx be dry and 
uncomfortable, the frequent sipping of warm milk, barley-water, gruel, or 
* treacle posset,' or the use of black currant -jelly, or such-like things, is 
often a source of considerable comfort. Sucking ice in many cases answers 
the same purpose. In the latter stages of faucial catarrh, or when the 
affection has become chronic, astringent applications, either in the form 



560 



DISEASES OF THE DIGESTIVE ORGANS. 



of gargles or of spray by means of the atomizer, may be useful. Occa- 
sionally, but, for the most part, as the result of repeated catarrhal attacks, 
the uvula gets elongated, and is believed to irritate the larynx, with which 
it comes in contact. Under such circumstances the tip may be readily and 
safely snipped off with scissors. 

It is very desirable to obviate, if possible, the liability to catarrh which 
so many persons labor under. There is no doubt that active exercise in 
the open air, and all other habits which tend to promote good health, tend 
also to diminish this liability ; and many a person will in his autumnal 
holiday expose himself with impunity to conditions which at home would 
certainly have brought on a severe attack. So far as possible, therefore, 
exercise and other health-conducive practices should be enjoined. It is 
not, however, the exposure which attends active exercise that as a rule 
induces cold, unless, indeed, the patient has undergone great fatigue and 
consequently fails to keep himself warm ; but it is rather the exposure 
when one is still, especially when one is still after previous violent exer- 
tion, and exposed to a cool breeze, to a cool draught of air, or to the cold- 
ness induced by wet clothes or the evaporation of sensible sweat. The 
means of obviating such dangers are too obvious to need enumeration. It 
is generally held, and we believe with reason, that a matutinal cold bath 
followed by friction with a rough towel, and then by walking or other ex- 
ercise, is a good preventive of colds. The shower-bath has been especially 
recommended for this purpose. It is, nevertheless, a fact that the con- 
tinued use of the shower-bath will in some persons, so far from obviating 
the liability to cold, induce it, and keep up a permanent catarrhal state. 



II. THRUSH. (Aphtha.) 

Causation and morbid anatomy Inflammatory affections of the mouth 

and fauces frequently arise in connection with stomach and bowel disturb- 
ance — sometimes simultaneously with it, sometimes secondarily to it, and 
more rarely, perhaps, as the first step in the order of events. Such in- 
flammations are sometimes catarrhal in the anatomical sense of the word-, 
and hence not readily distinguishable in all cases from the effects of ordi- 
nary cold. They do not, however, so far as we know, tend, as the latter 
variety does, to involve the nasal cavity and air-passages, or to extend to 
the eye, ear, sockets of the teeth, or branches of the fifth pair ; while, on 
the other hand, they involve the mucous membrane of the mouth much 
more prominently. 

Thrush is characterized for the most part by the appearance in greater or 
less abundance, on the tongue, gums, and palate, inside the lips and cheeks, 
on the soft palate, and pillars of the fauces, and even on the surface of the 
pharynx, of small, elevated, opaque, whitish spots, which are round or 
irregular in form, pretty firmly adherent, and not unfrequently appear like 
attached flakes of curdled milk. These can be easily separated, leaving 
more or less distinctly excoriated areae or ulcers behind; and appear to be 
due mainly to inflammatory overgrowth of the epithelium with tendency 
to its detachment. 

In some instances thrush presents a different character. It begins with 
the formation of minute white rounded elevations, which gradually increase 



THRUSH. 



561 



in size until individually they attain perhaps the bulk of a mustard-seed 
or tare. These are hemispherical in form, adherent by broad bases, 
smooth on the surface, and uniformly solid. They are scattered irregu- 
larly, sometimes sparsely sometimes in great abundance, on the lips, and 
other parts of the surface of the oral cavity and pharynx. Under the 
microscope these bodies are found to consist of the oval spores of a crypto- 
gamic plant, called the ' oidium albicans,' the mycelium of which infiltrates 
the subjacent epithelium. The source of this parasite has not been clearly 
ascertained, but Hallier regards it as identical with the oidium lactis. If 
this be so the explanation of its occurrence in infants at the breast, and in 
persons wasted with disease, is not too far to seek. 

It must be added that the oidium may often be recognized in the form 
of aphthae first described. It seems therefore probable, not only that it 
may be derived from milk ; but that it attacks the mucous membrane 
under various circumstances, sometimes directly, sometimes at the seat of 
excoriations or of inflammatory patches — in other words that aphthae are 
sometimes primarily, sometimes secondarily, parasitic. 

Symptoms and progress. — Aphthae are of very common occurrence in 
young children, more particularly infants at the breast ; but are frequent 
also in the course of many diseases, especially when they are attended 
with hectic fever or the typhoid state. In young children thrush is gener- 
ally preceded by and attended with feverish symptoms — heat of skin, fret- 
fulness, and drowsiness — diarrhoea, or other morbid conditions of the 
bowels, loss of appetite, vomiting, and unwillingness to take food. Gastro- 
intestinal disturbance, indeed, is rarely absent ; and it is believed by many 
that aphthae of the mouth indicate a similar condition of the stomach and 
alimentary canal. The lips usually are dry, and the tongue, especially at 
the tip and edges, redder and drier than natural, and with a tendency to 
get furred on the dorsum and towards the base. The anus and its vicinity 
in such cases are sometimes reddened and excoriated, and aphthae have 
been described as existing there. Aphthae may subside after a few days, 
or last continuously or with remissions for many weeks. Thrush is not in 
itself a dangerous affection or necessarily an indication of danger in the 
affection which it attends. It must not be forgotten, however, that it 
frequently accompanies gastro-intestinal lesions which prove fatal, and that 
its presence cannot but add something to the danger of an already dan- 
gerous disease. When thrush supervenes in the course of diseases affect- 
ing adults, although it is not necessarily an indication of impending death, 
it is yet often a symptom of grave omen. 

A trivial form of the affection is observed in persons who are liable to 
dyspepsia. The dyspeptic symptoms, which are probably inflammatory, 
are attended with stiffness and soreness of the back of the tongue and 
fauces, and sometimes of the anterior part of the tongue as well. There 
may be considerable pain on deglutition ; and acid or stimulating articles 
of diet, and such as are in hard and angular fragments, cause intolerable 
smarting. On inspection in some cases, little or no visible departure from 
the healthy condition can be observed ; in other cases, however, there is 
more or less obvious redness ; and often the presence of cracks or fissures, 
or even of small patches of excoriation along the edges of the tongue, and 
elsewhere at the back of the mouth, may be recognized. 

Treatment — In the treatment of thrush and of the forms of inflamma- 
tion related to it, it is important in the first place to attend to the general 
health and especially to the condition of the alimentary canal. In chil- 
36 



562 



DISEASES OF THE DIGESTIVE ORGANS. 



dren it is generally best to commence the treatment with a dose of castor 
oil, or of rhubarb in combination with carbonate of magnesia or gray 
powder, and then to administer medicines calculated to improve the tone of 
the stomach and bowels. According to the particular symptoms present may 
be prescribed lime-water with milk, small doses of rhubarb with ginger 
or some other aromatic, aromatic confection with chalk and opium, or 
vegetable bitters. Locally, relief may be given by the application of mel 
boracis, solution of tannin, sulphate of zinc, or nitrate of silver ; by wash- 
ing out the mouth with a solution of chlorate of potash ; by rinsing it with 
mucilaginous fluids ; or by the use of lozenges containing gelatine or muci- 
lage. With the object of destroying the parasite present in some forms of 
aphthae, solution of sulphurous acid has been strongly recommended. 



III. ULCERATIVE STOMATITIS. 

Causation and morbid anatomy A peculiar affection of the mucous 

surface of the cavity of the mouth is sometimes met with, chiefly if not 
entirely in children below the age of puberty, which has a close relation, 
at all events anatomically, to that observed in cattle affected with the foot- 
and-mouth disease. It is impossible to deny that there is also some re- 
semblance between this affection and both thrush and the early stage of 
gangrenous ulceration. Yet the appearances are so peculiar, and the whole 
progress of the affection so like that of a specific disease, that there is good 
reason to regard it as an affection sui generis. It consist in the formation of 
excoriated patches, chiefly limited to the surface of the gums, and corre- 
sponding parts of the cheeks, but occurring also on the dorsum and sides 
of the tongue, mainly towards the base, on the palate, and general surface 
of the buccal mucous membrane. The excoriations vary in size and shape, 
but are mostly irregular and tending to run together ; their surface is raw, 
red, and weeping, sometimes bleeding; and the surface of the mucous 
membrane between them is thickened and opaque. The tongue (except- 
ing the spots of excoriation) generally gets covered with a thick, tough, 
opaque, whitish fur, and its surface looks not unlike a piece of wash- 
leather. 

Symptoms and progress. — The approach of the malady is usually indi- 
cated by some degree of feverishness and malaise — symptoms, indeed, 
differing little if at all from those that usher in an ordinary cold. Then, 
after a day or tw r o, some soreness is experienced in masticating, speaking, 
and deglutition ; and if the mouth be examined, the morbid phenomena 
above described will be recognized in an early stage. The progress of the 
affection is attended with febrile symptoms — heat of skin, flushing of face, 
listlessness, drowsiness, thirst, loss of appetite, and the like. And these, 
together with the local phenomena, usually subside in the course of a week 
or ten days. In some cases the affection of the mouth assumes a more 
chronic character. We are not aware that it ever leads to serious conse- 
quences. 

Treatment. — For local treatment mel boracis, or chlorate of potash in 
solution, seems to be indicated. Internally, a little chlorate of potash or 
other febrifuge medicine may be administered. 



NOMA. 



563 



IY. NOMA. {Gangrenous Stomatitis.) GANGRENE OF FAUCES. 

A. Noma. 

Causation Gangrenous ulceration of the mouth occurs almost exclu- 
sively in children under twelve years old, and indeed is mainly limited to 
those whose ages lie between one and five. Its cause is not very obvious. 
There is no doubt, however, that it is especially apt to become developed 
during convalescence from acute febrile disorders, among which measles 
stands pre-eminent, and in children who have been badly fed or are anaemic. 

Morbid anatomy The gangrene may commence at any part of the 

buccal surface, and in several parts at one time. But it usually originates 
in the sulci between the gums and cheeks, and chiefly (according to Barthez 
and Rilliet) in those connected with the lower jaw. It begins variously: 
sometimes with ulceration or the formation of a superficial slough ; some- 
times with congestion, thickening and tension of the substance of the cheek 
or other soft parts circumscribing the oral cavity. In any case there soon 
appears on some part of the mucous surface of the mouth an irregular 
grayish or black sloughy patch surrounded with a rim of intense and some- 
what livid congestion. This tends to spread rapidly both in area and in 
depth — its extension being preceded and accompanied by infiltration, hard- 
ening, and congestion of the tissues. The cheek in the affected neighbor- 
hood frequently becomes tense, shining, and livid. With the extension of 
the gangrene, the gums may be eaten away, the alveoli necrosed, and, if 
the patient live sufficiently long, the teeth and portions of the jaw may ex- 
foliate, and the soft palate, fauces, and tongue, each and all, be more or less 
extensively destroyed. Very frequently the cheek gets perforated, and the 
destructive process may then spread almost indefinitely, involving in turn 
the mouth, the entire cheek, and it may be the nose, the eye, and other 
contiguous parts. 

Symptoms and progress The symptoms which attend noma are, at all 

events in many cases, much less severe than one would expect them to 
be. It often happens that the gangrene has made some progress in the 
interior of the mouth before anything has occurred to call special attention 
to what is going on there ; and indeed it is not a rare thing to find patients 
in whom gangrene has committed the most extensive and frightful ravages, 
and for whom recovery is hopeless, who neither suffer pain nor have suf- 
fered it, who maintain a good appetite, and continue sensible and even cheer- 
ful. The special symptoms, in addition to swelling of the cheek and the 
actual progress of the gangrene (which is obvious enough if looked for), 
are : more or less profuse salivation, the discharge often being bloody and 
foul ; extreme fetor of this discharge and of the breath ; and more or less 
swelling of the neighboring lymphatic glands. As above indicated, the 
patient often suffers very little pain or uneasiness, remains sensible, talks, 
and takes an interest in whatever is going on about him, and retains his 
desire for food and the power of taking it. But notwithstanding this, the 
pulse rises in frequency, and gets small and feeble ; the surface grows pale 
and cold; drowsiness or delirium comes on; diarrhoea perhaps sets in ; and 
death from asthenia supervenes at the end of a few days. In a small pro- 
portion of cases recovery takes place, with more or less deformity.. 



564 



DISEASES OF THE DIGESTIVE ORGANS. 



B. Gangrene of Fauces. 

Causation. — But gangrene, not specially limited in this case to young 
children, may commence in the fauces or pharynx. In some cases this is 
due to diphtheria or scarlet fever, or results from the mere intensity of the 
inflammation in ordinary tonsillitis. But it may also occur independently 
of such special diseases, and, like noma, be traceable to profound impair- 
ment of the general health. 

Symptoms and progress. — The symptoms in these several cases differ in 
some degree according to the nature of the disease to which the gangrene 
is due. Eliminating, however, the symptoms referable to the several spe- 
cific affections which have been named, gangrene of the fauces would be 
revealed by tumefaction of the tissues, the appearance of sloughs upon the 
surface, fetid discharge and breath, swelling of the glands beneath and be- 
hind the jaw, and, in addition to these phenomena, difficulty and pain in 
deglutition, and probably, before long, more or less difficulty of respira- 
tion. The situation of the morbid process necessitates the presence of 
much more pain and discomfort than are usually associated with noma ; 
and here, as in the other case, very extensive destruction of tissue may 
take place, and perforation ensue. The general symptoms are : feebleness 
of pulse, sometimes with quickening, sometimes with marked diminution 
of frequency ; pallor ; coldness of surface ; tendency to collapse ; and not 
unfrequently, before death, copious perspirations, diarrhoea, and impair- 
ment of consciousness, delirium or coma. 

C. Treatment. 

In treating gangrenous affections of the mouth and throat, it is in the 
first place of paramount importance that the patient's strength should be 
maintained by the regulated administration of nutritious food and alcohol, 
and of tonic medicines, or these combined with diffusible stimulants. 
Opium here, as in all similar cases, may be of great service. For local 
treatment, it is necessary to keep the parts cleansed ; to wash them fre- 
quently with antiseptic fluids, such as solutions of either chlorinated soda, 
chlorine, hydrochloric acid, permanganate of potash, or chlorate of potash ; 
and to treat the gangrenous tracts themselves freely with escharotics, of 
which probably the most yaluable are pure hydrochloric or nitric acid, 
and the actual cautery. 



Y. INFLAMMATION OF THE GUMS IN DENTITION. 

Cutting the teeth is always attended with more or less discomfort, if not 
absolute pain. Previous to the actual eruption, the implicated gum gene- 
rally becomes congested, swollen, and tense, and often distinctly inflamed. 
Occasionally suppuration or ulceration takes place. The eruption of the 
second teeth is seldom attended with symptoms which call for the notice of 
the physician. The eruption of the first set, however, is a fertile source 
of infantile ailments. This is especially the case when it occurs early. 
It is well known to mothers and nurses that infants who are on the eve 
of cutting their teeth begin to dribble and to bite the finger or any other 



GLOSSITIS. 



565 



hard substance which may be introduced into the mouth ; and, looking upon 
these symptoms as an indication for treatment, they give the babe an ivory 
or India-rubber ring or a piece of coral to bite. 

So far the symptoms may be regarded as normal ; but in many cases the 
congestion of the gum produces feverishness and fretfulness, interferes with 
the infant's rest, and induces sickness and diarrhoea. When these phe- 
nomena ensue, each may be treated according to its importance : the vom- 
iting may be allayed by the exhibition of some aromatic, or the addition 
of a small quantity of lime-water to the milk ; the diarrhoea may be recti- 
fied by the administration of a little castor oil or Gregory's powder, fol- 
lowed, if necessary, by a little aromatic confection and chalk ; the restless- 
ness may be met by minute doses of opium. In the great majority of cases, 
however, the most efficacious and the best treatment is freely to lance the 
inflamed gum. 

In some instances convulsions are referable to the irritation of the 
emerging teeth. Under such circumstances in addition to the appro- 
priate treatment for convulsions, lancing of the gums must be efficiently 
performed. 

Many other maladies besides the above are commonly regarded as con- 
sequences of dentition, the principal of them being eczema, lichen, and im- 
petigo in various forms, bronchitic affections, and paralysis. It is doubtful, 
however, whether dentition has any other effect upon them than that of 
aggravating them. 



VI. GLOSSITIS. 

Causation — Besides the superficial forms of inflammation in which the 
tongue shares with the other parts bounding the oral cavity, the organ is 
liable to become inflamed throughout its whole substance. This occurrence, 
which is rare, may take place under the influence of the mercurial poison, 
or as a consequence of direct injury, but now and then arises independently 
of all such obvious causes. 

Symptoms and progress — Idiopathic glossitis is said to be preceded in 
some cases by premonitory febrile symptoms. In other cases the inflam- 
mation is certainly, so far as one can judge, primary, although attended, 
probably from the commencement with more or less febrile disturbance, 
and even with rigors. It sometimes commences in the tongue itself, at 
other times in neighboring parts, especially the fauces. The tongue then 
becomes swollen, stiff, and painful, and incapable of executing its proper 
functions. The swelling is usually general, although sometimes limited to 
one-half, or it may be some lesser portion. In the first case the organ gets 
enlarged in all its dimensions, sometimes so thick as to render inspection 
of the back of the mouth out of the question, so wide as to project on either 
side between the molar teeth, so long as to protrude beyond the lips, and 
even exerting serious pressure upon the upper part of the larynx. The 
pain is usually of a throbbing or burning character, and increased by all 
attempts at movement, so that mastication, deglutition, and articulation 
are in some cases almost impossible. Saliva accumulates in the mouth, 
and the patient's sufferings consequently become much aggravated. The 
surface of the tongue may in the first instance be redder than natural, but 
very soon gets enveloped in a thick white creamy fur. Occasionally sup- 



566 



DISEASES OF THE DIGESTIVE ORGANS. 



puration takes place and an abscess forms. The affection usually attains 
its height, in the course of three or four days, and, if free from complica- 
tion, subsides in the course of a week or ten days. Permanent hypertro- 
phy of the tongue has sometimes resulted. 

The sufferings of a patient with glossitis are usually out of proportion to 
his danger. Some of them have already been referred to ; but one of the 
most serious is the sense of impending suffocation which is often present, 
and which alone may be sufficient to prevent all sleep and forbid even tem- 
porary ease. It is quite possible, however, that from extension of oedema 
or inflammation to the larynx dangerous symptoms, and even death, may 
ensue. The disease, therefore, is one which needs close and careful 
watching. 

Treatment The patient should have his mouth cleansed, by gargling 

(if he can effect it) or otherwise, with solution of chlorate of potash or other 
detergent lotions ; his strength should be sustained with liquid nourishment, 
which, if it cannot be swallowed, should be administered by the nose or 
rectum. Fomentations may be applied to the throat externally, and even 
leeches may be deemed advisable. It may also be necessary (and the 
practice is very efficacious) either to apply leeches to the tongue itself, or 
to make longitudinal incisions into it. If an abscess form it should of 
course be opened. For general treatment, febrifuges may be given ; and 
opium is of paramount value. It requires, however, to be given with 
much caution. If suffocation threaten, tracheotomy may be performed. 



VII. QUINSY. (Tonsillitis.) 

A. Acute Tonsillitis. 

Causation The surface of the tonsil becomes inflamed in a greater or 

less degree whenever spreading or general inflammation involves the mu- 
cous membrane of the mouth and fauces. Hence, in catarrh, aphthae, and 
the like, the tonsils are necessarily implicated. Again there are several 
affections in which inflammatory involvement of the substance of the ton- 
sils forms an important and characteristic feature. We especially refer to 
scarlet fever and diphtheria. Deep-seated or parenchymatous inflamma- 
tion of the tonsils, however, is like ordinary catarrh a frequent consequence 
of exposure to cold or wet ; the two conditions, indeed, are not unapt to 
concur. Nevertheless it is a fact that many persons who are subject to 
catarrh, with all its usual associations, never suffer by any chance from 
tonsillitis ; and it is equally a fact that tonsillitis often occurs independ- 
ently of the special symptoms of catarrh. The symptoms and course of 
tonsillitis, moreover, are very characteristic, and the affection, therefore, 
calls for independent consideration. Tonsillitis is mostly a disease of 
childhood, but when once it has developed, it is apt to recur, and thus to 
be perpetuated into the period of adult life. 

Morbid anatomy Simple or non-specific inflammation of the tonsils 

is characterized by inflammatory swelling of the tonsils themselves and of 
the soft tissues in their immediate neighborhood, especially the pillars of 
the fauces, the soft palate and uvula, the base of the tongue, and the pha- 
rynx. The tonsil (for one is generally first and often solely affected) 
becomes increased in size, deeply congested, and infiltrated with inflam- 



QUINSY. 



567 



matory exudation and growth. The crypts upon its free surface produce 
superabundant epithelium, which accumulates in their orifices, forming 
opaque, yellowish, creamy pellets. The lymphatic nodules of the interior 
undergo inflammatory overgrowth, and often soften, suppurate, and run 
together, and ultimately form an abscess. The soft palate and pillars of 
the fauces become of a vivid red hue, swollen, tense, and shining, and 
more or less displaced ; and thus, if the swelling of the tonsil and sur- 
rounding parts be extreme, we find the soft palate on the affected side 
pushed downwards, forwards, and inwards, the anterior faucial pillar cor- 
respondingly displaced, and both together forming a smooth, tense, vividly 
red swelling, with the convexity facing forwards. The swelling and dis- 
placement indeed of the surrounding parts are sometimes so great that the 
enlarged tonsil itself is almost concealed. When both tonsils are involved, 
their affection is sometimes concurrent, more frequently in sequence. 
Often indeed the one is getting well when its fellow first shows signs of 
disease. When the tonsils are both very large, they may meet one an- 
other in the mesial line, becoming flattened and sometimes ulcerated from 
mutual pressure, and between them almost completely closing the faucial 
canal. The uvula, which is usually swollen, tense, and congested, often 
clings to one of them : it may be so much elongated as to hang into the 
upper part of the larynx. Further, the tongue gets covered with a thick 
creamy fur, and the glands at the angle of the jaw, and sometimes the 
salivary glands, share in the inflammation, and become hard and large. 

Symptoms and progress. — The invasion of tonsillitis is almost always 
marked by the occurrence of severe febrile symptoms, associated with 
soreness, itching, or tingling, dryness and aching in the region of the 
fauces. The febrile symptoms increase in severity with the increase of 
the local affection, and with the cessation of the latter gradually, or it may 
be, suddenly subside. At the beginning the patient experiences alternate 
flushes of heat and chills, and even distinct rigors ; his temperature rises, 
and often reaches an elevation of at least 102° ; not unfrequently, indeed, 
by the time the disease has attained its maximum, it mounts to 104° or 
even 105° and upwards; his pulse increases in frequency, rising to 100 or 
120, and is at the same time more or less full and firm; his skin is hot 
and pungent, but with a marked tendency to remittent sweats ; he com- 
plains of headache, pains in the back and limbs, thirst and anorexia ; his 
bowels are confined, his urine dark-colored and scanty. The appearance 
which the tonsils and interior of the mouth present may be gathered from 
the description which has been given of these parts. It remains to say 
that the patient has severe pains at the back of the throat and base of the 
tongue whenever he moves his jaws, or speaks, and especially whenever he 
opens his mouth widely or attempts to swallow. The pain then not un- 
frequently shoots along the Eustachian tubes to the ears. He has a con- 
stant desire to swallow in order to relieve his uneasiness, but the pain and 
difficulty of swallowing are so great that he permits the secretions to accu- 
mulate in his mouth ; and, in attempting to swallow, fluids not unfrequently 
pass up into the nose. The quality of the voice is nasal and characteristic. 
There is often deafness, and always more or less fulness and tenderness 
behind the angles of the jaw. The swollen tonsils indeed may be felt in 
these situations. If one tonsil only be inflamed, or both be simultaneously 
affected, the malady will probably attain its height in three or four days, 
and end in convalescence at the end of a week or ten days. Occasionally 
its course is yet more rapid, and the patient is well, or nearly so, in three 



568 



DISEASES OF THE DIGESTIVE ORGANS. 



or four days. But when one tonsil is affected after another, the course of 
the disease is necessarily protracted. If an abscess form, as is usually the 
case when the attack is severe, the severity of the symptoms progressively 
increases up to the moment at which the abscess breaks. Then the tonsil 
suddenly shrinks within moderate dimensions, and the patient is probably 
at once restored to comparatively good health. The matter which escapes 
is fetid and thick, and usually swallowed. The symptoms of tonsillitis are 
severe out of all proportion to the seriousness and danger of the affection. 
Any other termination than that of recovery within a brief period is very 
rare. The interference with swallowing, which seems so serious, never 
prevents the taking of food for more than a very limited period. Occa- 
sionally, however, death results from suffocation, due either to the sudden 
bursting of a large abscess and the entrance of its contents into the larynx, 
or to the mechanical impediment which the inflamed and swollen parts 
interpose to respiration. 

Treatynent. — Tonsillitis is one of that large number of diseases which 
take their own course. It may, nevertheless, be relieved by appropriate 
measures. The patient should be submitted to the same plan of general 
treatment that has already been recommended as suitable for catarrh. Nor 
need there be much difference in respect of local treatment. Hot fomen- 
tations, or flannel, or cotton-wool may be applied to the exterior of the 
throat ; and the patient be persuaded to gargle his fauces frequently with 
warm milk, or to allow the steam of boiling water to play upon them, or 
to suck black-currant jelly and such-like substances. Swallowing lumps 
of ice, however, and the application of ice-cold compresses to the neck 
often give far greater relief than warmth. Astringent and stimulating 
gargles are often recommended, as is also the application of nitrate of silver. 
Such treatment, however, is more suitable to the period of convalescence, 
at which time also tonics and good food may be specially needed. Opium 
judiciously administered generally gives great relief. When the swelling 
of the tonsil is extreme and the congestion intense, and the patient at the 
same time is suffering severely, relief may sometimes be afforded by scari- 
fying or puncturing the tonsil. The value of such treatment, however, is 
chiefly seen when suppuration has taken place. Care should be exercised 
in puncturing the tonsil not to wound the large vessels which run along 
its outer aspect. The point of the lancet should be directed backwards, 
with an inclination inwards. But even if no large vessel be injured, dan- 
gerous hemorrhage occasionally ensues. 

B. Chronic Tonsillitis. 

Symptoms and progress As a consequence, sometimes of frequently 

repeated attacks of acute tonsillitis, sometimes of chronic inflammation, 
the tonsils undergo gradual hypertrophy, and form indolent tumors, which 
more or less seriously diminish the size of the faucial passage, and occa- 
sionally come into actual contact with one another. The presence of such 
tumors may be scarcely apparent to the patient himself ; but in many cases, 
especially if large, they give a peculiar quality to the voice, which is in- 
describable, but impossible not to recognize when once it has been pointed 
out ; and not unfrequently there is associated with them some chronic 
thickening of the mucous membrane of the pharynx and Eustachian tubes, 
with more or less deafness. Further, such patients are generally liable to 
frequent exacerbations of the affection. 



RETRO - PHARYNGEAL ABSCESS 



OZCENA. 



569 



Treatment Tonic medicines, iron and quinine and the like, good diet, 

fresh air and healthful exercise are of essential value in the treatment of 
chronic tonsillitis. It is commonly held that the application of strong 
solutions of nitrate of silver or of the solid caustic, or other such agents, 
is serviceable in promoting the disappearance of these bodies. Such ap- 
plications are no doubt frequently beneficial in allaying inflammation 
affecting their surface. But the only effectual way of dealing with them 
is to remove them by the knife. 



VIII. RETRO-PHARYNGEAL ABSCESS. 

Causation. — Retro-pharyngeal abscess is usually due to caries of the 
cervical vertebrae, and is sometimes one of its earliest indications ; it may 
be connected also with suppuration in and about the tympanum and Eusta- 
chian tube, even when the bone is not involved. We have met with it in 
a case of aortic aneurism. 

Symptoms and progress — A retro-pharyngeal abscess is situated, as its 
name indicates, between the posterior wall of the pharynx and the anterior 
aspect of the vertebras, and forms a convex protrusion of greater or less 
extent and prominence at the back of the pharynx. It may be so high 
or so low as to escape detection by the usual method of observation ; but 
in most cases it forms a visible bulging at the back of the throat. It is 
sometimes symmetrical, sometimes more or less one-sided, soft and yield- 
ing to the touch, and not necessarily presenting superficial congestion. It 
is liable to undergo perforation from time to time, to allow of a more or 
less free temporary escape of matter, and consequently to vary in bulk. 
Its presence is sometimes productive of pain and difficulty in swallowing, 
and has been known to impede respiration and even to cause death by 
such impediment ; but not unfrequently it is, for a time at least, simply a 
source of discomfort to the patient, in consequence of the pus which it 
exudes, the foul taste which it gives, and the fetor which it imparts to the 
breath. The progress of the abscess mainly depends on that of the disease 
which produces it. 

The treatment, apart from the use of tonics, which is generally clearly 
indicated, is essentially surgical. 



IX. OZCENA. 

Causation — This term is applied to all those cases which are attended 
with fetid discharge from the nose. The causes of ozoena are in some 
cases mere chronicity of inflammation of the mucous surface, in some ulcer- 
ative destruction or gangrene, and, in a large proportion of cases, caries 
or necrosis of the nasal bones. These several morbid conditions are for 
the most part connected, either with a scrofulous condition, with syphilis, 
with lupus, or with polypoid or malignant growths occurring in the nasal 
cavities. 



570 



DISEASES OF THE DIGESTIVE ORGANS. 



Symptoms — The discharge which escapes from the nostrils varies con- 
siderably both in character and in quantity. Sometimes it differs little in 
appearance from ordinary mucus, often it is thick and purulent, sometimes 
it contains blood, sometimes it is thin and ichorous. It frequently also 
tends to concrete in the cavities of the nostrils into thick crusts. The 
accumulation of unhealthy discharges in the antrum and other sinuses con- 
nected with the nose often leads to their decomposition, and to fetor; and 
the escape of such discharges is apt to take place at irregular intervals. 
The nature of the stench which is emitted varies greatly both in quality 
and in intensity. In some cases it is horribly disgusting. Ozoena is gene- 
rally attended with more or less complete loss of smell. 

The source of fetor may, even in the absence of discharge, be readily 
ascertained by making the patient respire alternately through the mouth 
and nose, and ascertaining under which of these conditions it is chiefly 
developed. 

Treatment For this purpose the determination of the cause is of funda- 
mental importance. If it be syphilitic, antisyphilitic remedies must be 
given; if connected with enfeebled constitution, tonics and good diet must 
be enjoined. Under any circumstances the nose should be kept clean ; it 
should be frequently washed out by means of either a syringe or the nasal 
douche, with a weak alkaline solution, or a weak solution of quinine, Condy's 
fluid, chlorinated soda, chlorate of potash, or carbolic acid; and either 
stronger solutions of the same agents should be occasionally employed as 
injections, or appropriate powders should be frequently blown in or sniffed 
up. For the latter purpose Trousseau especially recommends bismuth 
diluted with an equal part of some inert powder, or white precipitate mixed 
with about forty times its weight of finely powdered sugar. [A weak 
solution of chloral, used as a nasal injection, will often be found very effi- 
cacious in overcoming the horrible fetor of the discharge.] 



X. MORBID GROWTHS. 

A. Tubercle. — Miliary tubercles are described by Virchow as occasion- 
ally affecting the mucous surface of the tongue, palate, and nose, and there 
producing shallow sinuous ulcers, such as characterize the tubercular pro- 
cess in other mucous membranes. Miliary tubercles are difficult of recog- 
nition in these situations during life; at the same time it is a fact that 
shallow, intractable ulcers, not improbably due to this cause, are not alto- 
gether uncommon in the fauces and soft palate of phthisical patients, even 
at an early period of their disease. 

B. Syphilis. — Syphilis in its secondary and tertiary stages, is very apt 
to affect the tract of mucous membrane now under consideration. 1. Ery- 
thematous patches, for the most part symmetrical, may appear on the 
pharynx or palate, inside the lips, or elsewhere in the mouth during the 
prevalence of the secondary cutaneous eruption. 2. Mucous tubercles may 
get developed during the same period, principally on the lips, dorsum and 
edges of the tongue, tonsils, and palate, and in the pharynx ; and shallow 
ulcers, secondary to these tubercles, or of independent origin, are not un- 
freqnent in the same situations. 3. At a later period of the disease deep 
ulcers appear, most commonly in the soft palate, tonsils, fauces, and pharynx, 



DISEASES OF THE (ESOPHAGUS. 



571 



frequently spreading in a serpiginous manner, and gradually involving a 
wide extent of surface or penetrating deeply, and in either case leading to 
serious destruction of tissue. 4. Lastly, gummatous tumors are not un- 
commonly developed in the soft palate, and pharynx, but more especially 
in the substance of the tongue. 

For a further account of these affections, and their treatment, we must 
refer to the article upon syphilis. 

C. Malignant tumors Tumors of various kinds originate in, or involve, 

the mucous membrane of the mouth and fauces, or the organs which are 
contained within the mouth. But it scarcely falls within the province of 
the physician either to investigate or to treat them. Malignant affections 
of these parts alone have any medical interest. They are not uncommon. 

In persons advanced in years, epithelioma of the lips (more especially 
of the lower lip) is apt to occur; in those who have attained or passed 
middle life a similar affection of the tongue is not uncommon; and not 
unfrequently, under the same circumstances of age, malignant disease, 
mostly epithelioma, but sometimes carcinoma, sometimes sarcoma, becomes 
developed in some part of the fauces or pharynx. Again, malignant tumors 
(commonly some soft variety of carcinoma or sarcoma) occasionally form 
in connection with the mucous membrane of the nose, for the most part in 
young children or persons advanced in life. Further, sarcomatous and 
carcinomatous tumors, originating either in periosteum or in bones, form 
outgrowths from the bones of the upper and lower jaws, from those bounding 
the nasal cavity, and from the cervical vertebrae. 

Malignant tumors of the mucous membrane are nearly always primary; 
they are often slow and insidious in their progress, and apt at first to be 
mistaken for some trivial affection; they are especially liable when they 
have made some progress to be confounded with syphilitic affections. 
That they are not syphilitic is, however, soon revealed by the total inope- 
rativeness upon them of antisyphilitic treatment, and by their further 
progress. They gradually and surely invade the surrounding textures, 
gradually ulcerate and slough — causing more and more extensive destruc- 
tion and yielding a foul discharge — and always before long involve the 
neighboring lymphatic glands. These then form gradually enlarging 
tumors, which presently undergo precisely the same changes as the pri- 
mary tumor. The diagnosis of these cases, which is often very uncertain 
in the beginning, rests mainly upon microscopic examination and on care- 
ful observation of their gradual and characteristic progress. 

Their treatment is purely surgical. 



Section II. — DISEASES OF THE (ESOPHAGUS. 

I. INTRODUCTORY REMARKS. 

Anatomical relations — The oesophagus commences at the cricoid carti- 
lage, opposite the low r er border of the fifth cervical vertebra, and runs 
down along the spine, a little to the left side, as far as the ninth dorsal 
vertebra, opposite which it penetrates the diaphragm and opens into the 
stomach. In the neck it has the trachea in front of it, with the recurrent 



572 



DISEASES OF THE DIGESTIVE ORGANS. 



laryngeal nerves between them, and on either side the common carotid 
artery. In the chest it is covered in front by the lower part of the trachea 
and then crossed by the left bronchus, after which it. comes into contact 
with the pericardium. On either side of it is the pleura. The transverse 
and descending arch of the aorta cross the front and left side of the oeso- 
phagus on the level of the second and third dorsal vertebrae ; and the 
thoracic portion of that vessel lies to its left and behind it throughout the 
rest of its course, excepting just as it perforates the diaphragm, when the 
aorta slips altogether behind it. 



II. INFLAMMATION OF THE OESOPHAGUS. 

Causation and morbid anatomy — The oesophagus is liable to share in 
all those inflammatory conditions which affect the pharynx and larynx. 
We have pointed out that the inflammation of a simple 1 cold' may travel 
downward along this tube ; and when inflammation of special intensity 
involves the organs in relation with it, the oesophageal inflammation may 
be equally intense. Occasionally, indeed, under such circumstances thick- 
ening of its walls, with purulent infiltration of them and of the surround- 
ing connective tissue, may extend from the pharynx to the cardiac orifice 
of the stomach. Further, the specific eruptions of some of the infectious 
fevers may involve the oesophagus, the diphtheritic false membrane may 
pervade its whole extent, and aphthous patches may form here and there 
upon it. Inflammation is sometimes also the result of swallowing boiling 
water or corrosive substances, such as the mineral acids, caustic alkalies, 
and other chemical agents. 

Symptoms In nearly all the above cases the oesophageal inflammation 

is associated with similar but probably more severe inflammation, either 
of the larynx, pharynx, and fauces above, or of the stomach below ; and 
the graver symptoms of these other affections tend to mask more or less 
completely the presence of the oesophageal complication. The special 
indications of inflammation of the oesophagus are : the presence of heat 
and pain in the course of that tube ; aggravation of pain in the same situa- 
tion during the act of swallowing, and in very severe cases inability to 
swallow ; and tenderness on pressure applied to the neck in the situation 
of the oesophagus. The absence, however, of such symptoms does not 
disprove the presence of either general slight inflammation, or limited 
tracts of inflammation. 



III. CHRONIC AND OBSTRUCTIVE DISEASES OF THE 
OESOPHAGUS. 

A. Ulceration. 

Causation and morbid anatomy — The most frequent cause of ulcera- 
tion is either mechanical violence, or the operation of destructive re-agents, 
to which may be added perforation of the oesophagus from without. 



DISEASES OF THE (ESOPHAGUS. 



573 



Small ulcers and mere excoriations doubtless get well, as a rule, without 
leaving any permanent ill effects behind ; but when ulcers are extensive 
and deep, even though they be tree from any malignant taint they are liable 
sooner or later to induce serious results. Of these the most important is 
cicatrization, with consequent contraction of the calibre of the tube, and 
the supervention of a stricture which tends to become more and more tight. 
Other results are the formation of a sinus between the oesophagus and 
trachea, or left bronchus, and the perforation of an artery. 

B. Morbid Growths. 

Morbid anatomy. — The oesophagus is occasionally the seat of syphilitic 
disease with ulceration which by cicatrization may cause more or less serious 
contraction and obstruction. Of all adventitious formations, however, the 
most common and the gravest are of a malignant character. These are 
chiefly met with after the age of 40 or 45, and in the great majority of 
cases are of primary origin. The most frequent variety of malignant dis- 
ease, probably, is epithelioma : but encephaloid and scirrhous cancers are 
not unfrequent ; and colloid cancer also has been observed. The seat of 
the disease is very various. In some cases it occupies the upper extremity 
of the tube, probably then involving also the contiguous pharynx and lar- 
ynx ; in some cases it is found at the lower extremity, when it is often 
associated with similar disease of the neighboring cardiac extremity of the 
stomach ; but in the greater number of cases it occurs in some intermediate 
spot, and very frequently in that part of the tube which is in relation with 
the trachea and bronchi. The affection, when primary, usually commences 
at some spot in the thickness of the mucous and submucous tissues, whence 
it spreads : superficially, so that before long it probably occupies three or 
four inches of the length of the oesophagus and its whole circumference ; 
and in depth, so that sooner or later it implicates the whole thickness of 
the walls, and probably invades also the trachea or other neighboring tis- 
sues and organs. The free aspect of the growth is at first somewhat 
nodulated ; but the nodules running together soon form more or less flat- 
tened elevations, in connection with which, before long, ulceration, slough- 
ing, and the formation of fungous outgrowths take place. The thickened 
walls and nodulated outgrowths reduce the calibre of the oesophagus, and 
sometimes render it almost impervious. The subsequent ulcerative de- 
struction occasionally leads to its imperfect restoration. When the disease 
is of the colloid variety, the close-set vesicles of the growth open on the 
mucous surface, and abundant, clear, glairy fluid escapes. 

In the progress of malignant disease various accidents are apt to arise. 
Sometimes the trachea or left bronchus gets perforated, and a more or less 
free communication between it and the oesophagus established ; sometimes 
the oesophagus opens into the posterior mediastinum, or externally, or 
communicates by ulceration with one of the oesophageal or intercostal ar- 
teries, or the left subclavian. And besides the mere spread by contiguity 
(esophageal malignant growths, like those of other parts, soon cause secon- 
dary disease in the neighboring lymphatic glands, and, if the patient survive 
sufficiently long, disease of remote organs. The involvement of lymphatic 
glands, especially if they be those of the neck, is very often valuable as an 
aid to diagnosis. Further, it not very unfrequently happens that the re- 
current laryngeal nerve, especially that of the left side, gets implicated, 
and paralysis of the corresponding vocal cord induced. 



574 



DISEASES OF THE DIGESTIVE ORGANS. 



C. Affections implicating the (Esophagus from without. 

Causation and morbid anatomy. — The oesophagus is apt to be pressed 
upon or otherwise affected by tumors and other morbid conditions origin- 
ating externally to it ; and the patient's sufferings in many such cases are 
mainly, if not entirely, due to interference with the functions of this canal. 
Thus it may be compressed by an overgrown thyroid body encircling the 
trachea and acting upon it laterally ; by a carotid or innominate aneurism, 
or an aneurism of the descending arch or thoracic aorta ; by enlargements 
of the bronchial glands and other mediastinal growths ; by tumors springing 
from the vertebrae ; by abscesses ; and even by a distended pericardium or 
dilated auricles. 

Again, aneurisms and abscesses not unfrequently open into the oesophagus 
with a sudden and copious escape of blood or pus. Occasionally they open 
simultaneously into the oesophagus and trachea or one of the bronchi, 
causing more or less free communication between these tubes. And fur- 
ther, rupture of an aneurism of the lower part of the thoracic aorta occa- 
sionally causes an accumulation of coagulum around the cardiac end of the 
oesophagus with complete obstruction of its passage. 

D. Dilatation. 

Causation and morbid anatomy. — Whenever a stricture of the oeso- 
phagus has existed for any length of time, a tendency shows itself for the 
part of the tube below to contract and even to undergo atrophy, and for 
the part of the tube above to become dilated and at the same time hyper- 
trophied in respect of its muscular parietes. The same results indeed 
follow here as follow in the case of the bladder when there is stricture of 
the urethra. This dilatation and hypertrophy are in the majority of cases 
not strikingly apparent; sometimes, however, they are considerable, and 
especially when the stricture is situated low down, is non-malignant, and 
has been in existence for many years. Under such circumstances the 
oesophagus becomes dilated either in its whole length, or in a part of its 
length only, forming an elongated pouch, which may have a circumference 
of five or six inches. Such dilatations are sometimes discovered in cases 
where their development cannot be traced to the existence of any me- 
chanical impediment. It seems obvious, however, that they must even 
here be due, partly to distension by accumulated contents, and partly to 
powerful and sustained efforts of the muscular tunic to drive these contents 
onwards ; and that hence there must have been in the first instance some 
weakness or sluggishness of the tube, some virtual impediment, permitting 
of such accumulation. 

E. Spasm and Paralysis. 

Spasmodic stricture of the oesophagus generally occurs in nervous per- 
sons, and especially in hysterical women. It may appear, however, without 
obvious cause, in persons of quite different nervous organization ; and not 
unfrequently supervenes in the course of organic oesophageal disease, 
causing temporary aggravation of the patient's symptoms. 

Paralytic conditions of the oesophagus are rare. They may be hysterical, 
or dependent on profound affection of the central nervous organs. 



DISEASES OF THE (ESOPHAGUS. 



575 



F. Symptoms. Dysphagia. 

A common symptom of nearly all the above lesions is dysphagia, or 
difficulty or pain in swallowing. It is this symptom, indeed, which gene- 
rally first attracts attention to the oesophagus as the seat of disease ; and it 
is only by the subsequent history of the case, by the supervention or non- 
supervention of other phenomena — oftentimes mere hints — that we are 
enabled, w T ith more or less accuracy, to ascertain the exact nature of the 
disease which is present. 

But dysphagia is a symptom of many other morbid conditions besides 
these ; and especially of affections of the mouth, fauces, larynx, and 
pharyx. But dysphagia, due to morbid states of the parts here enume- 
rated, is for the most part merely a subordinate symptom of diseases 
otherwise well characterized. It is very different, however, when the 
impediment to swallowing exists in the course of the oesophagus ; it is then 
not merely a symptom, but it is the symptom by which alone, in many 
cases, the presence of disease is indicated. 

The symptoms of organic obstruction are usually of slow development ; 
the patient perhaps first experiences an occasional hitch in the passage of 
food to the stomach — a hitch which is chiefly obvious when solids are being 
swallowed. This is variable, partly because the bulk and character of the 
swallowed bolus differ from time to time, and partly from the occasional 
superaddition of more or less spasmodic contraction. Further, it is pro- 
bably always referred to a definite point, and is not unfrequently associated 
with more or less well-marked soreness or pain there. For some time 
probably these symptoms have little attention paid to them ; but gradually 
they increase in severity and constancy, and attend the swallowing of both 
liquids and solids; further, the food before long begins to accumulate above 
the seat of obstruction, and hence to be regurgitated after a longer or 
shorter period of time with a kind of gulp — an effort which often has 
little or no resemblance to ordinary vomiting. The patient then finds it 
necessary to restrict his diet to slops, and ere long finds that he can take 
even such food as this only in the smallest quantities, and with difficulty 
and distress. He then rapidly emaciates, and if no fatal complication 
ensue, dies after a shorter or longer period of suffering from simple starva- 
tion. Such deaths are usually exceedingly distressing, because the patient, 
as a rule, retains his mental powers unimpaired to the last, and craves for 
nourishment which cannot be administered to him. These are the general 
symptoms of oesophageal obstruction ending fatally. But the progress of 
the case is usually largely modified by the nature of the disease on which 
it depends. 

If the case be one of simple stricture from a cicatrix, its course is gene- 
rally much protracted. And although such cases are often ultimately fatal, 
instances are on record in which patients have lived, though with more or 
less discomfort, to a good old age, and have then died of some other ail- 
ment. It is in them especially that dilatation of the tube above the 
stricture with compensatory hypertrophy takes place — conditions which, 
confined within certain limits, tend to neutralize the effects of the stricture. 

If the case be one of malignant disease, this fact is often for a while 
incapable of determination. The points which specially indicate it are : 
the comparative rapidity with which the case goes on from bad to worse ; 
the advanced age of the patient ; the appearance of indurated glands in the 
neck ; and the discharge from the oesophagus, in company with regurgi- 



576 



DISEASES OF THE DIGESTIVE ORGANS. 



tated food, of offensive, puriform, or sanious matter or detritus. Further, 
the sudden discharge of blood in large quantity, or the establishment of a 
communication between the oesophagus and air-passages, strongly indicates, 
though it does not absolutely prove, the presence of a malignant ulcer. 

The symptoms due to the pressure of external growths differ but little 
from those arising from actual disease of the oesophageal walls ; indeed the 
latter usually after a time become distinctly implicated. To aid our diag- 
nosis we must carefully explore the neck and thorax, in order to ascertain 
whether there be an enlarged thyroid body, a mediastinal growth, an 
aneurism, or any other form of tumor. But although in many such cases 
we may be enabled to form a correct diagnosis, in many all our efforts will 
necessarily be fruitless. 

We have stated that organic obstruction is usually of slow development; 
nevertheless it occasionally arises with sudden completeness. In the case, 
for example, of obstruction from the compression exerted by a circle of 
effused blood around the cardiac orifice, the symptoms occur quite sud- 
denly, and the patient dies probably of starvation at the end of ten days 
or a fortnight. 

An important point in reference to oesophageal obstruction is to ascer- 
tain its exact seat. It is important, partly in connection with the treat- 
ment to be adopted, partly as an element in determining the exact nature 
of the obstruction. Its site may be pretty correctly determined in many 
cases by the sensations of the patient. Jt is often indicated to some extent 
by the phenomena which follow the ingestion of a few mouthfuls of milk 
or other food ; thus, if it be at quite the upper part of the tube, regurgita- 
tion immediately follows the act of deglutition, and is probably attended 
with the intrusion of some of the fluid into the larynx ; if it be seated near 
the cardiac orifice, the return of food may be delayed for some seconds or 
minutes. It is, however, on the passage of the bougie, and the determina- 
tion of the exact point at which its progress gets arrested, that our main 
reliance must be placed. Another useful method is that of auscultating the 
oesophagus. If the stethoscope be applied to the back in the course of 
this tube, and the person examined be made to swallow a mouthful of some 
fluid, its momentary passage in the form of a compact mass is distinctly 
audible. If, however, an impediment exist, especially if the impediment 
be considerable, there will be some obvious delay in the passage of the 
mass at its seat ; and, moreover, the mass, instead of passing in a compact 
form, will probably trickle through in driblets, and its passage be attended 
with comparatively prolonged gurgling. It is not sufficient, however, to 
determine on one occasion the existence of gurgling at a particular spot. 
We must ascertain, by repeated observation, whether that localized gur- 
gling is permanent or not. 

Dilatation alone of the oesophagus is an impediment to the act of degluti- 
tion. The presence of dilatation even if there be muscular hypertrophy, 
necessarily renders the oesophagus a less efficient instrument for the propul- 
sion of its contents. These, instead of being driven readily and rapidly 
onwards, accumulate in the flaccid bag, and thence find their way fitfully 
into the stomach. One of the most interesting phenomena connected with 
dilatation is the tendency which there oftenis for the accumulated contents of 
the tube to be regurgitated by an effort, more or less voluntary, into the 
mouth, as in the act of rumination. 

Spasmodic stricture is apt to come and go more or less suddenly, and, if 
it be long continued, to present intermissions or variations of severity. It 



DISEASES OF THE (ESOPHAGUS. 



577 



is attended with many of the symptoms of organic stricture, and may even 
lead to death by starvation. The diagnosis rests partly on the patient's 
history and general state of health, partly on the variableness of the oeso- 
phageal obstruction, and partly on the evidence furnished by the unopposed 
passage of the bougie. 

The symptoms due to paralysis of the gullet are also mainly those of ob- 
struction. The food fails to be transmitted onwards to the stomach, and 
at the same time tends to accumulate in the tube and to distend it. The 
bougie passes without impediment. 

G. Treatment. 

(Esophageal obstruction is, in a very large proportion of cases, difficult 
and unatisfactory of treatment. If it be functional only, the passage of a 
bougie will sometimes at once restore the capability of swallowing. The 
permanent cure, however, of such cases is to be obtained only by curing 
the nervous conditions on which the obstruction depends. If, on the other 
hand, the obstruction be organic, the tendency of the disease is to render 
the occlusion of the tube more and more complete, and actual cure is prob- 
ably out of the question. We have no drugs which promote the absorption 
of cicatricial bands, or of carcinomatous or other tumors. We can, how- 
ever, in some cases, by surgical means, check the progress of contraction, 
and even cause dilatation of a part already strictured. We have pointed 
out the importance, for diagnostic purposes, of passing an oesophageal bou- 
gie. The careful passage of a bougie through a stricture, and the repeti- 
tion of the operation at intervals with instruments of gradually increasing 
size, will not only aid us in diagnosis, but in some cases relieve the stric- 
ture materially, and maintain that relief. The passing of a bougie, how- 
ever, through an obstructed oesophagus is an operation of much delicacy, 
and attended with no inconsiderable danger, especially if the impediment con- 
sist of a tract of soft ulcerating cancerous material, or be due to the pres- 
sure of a thoracic aneurism. The bougie may in fact, under such circum- 
stances, readily form a false passage into either the trachea, the mediastinum 
or the cavity of an aneurism, and so induce speedily fatal symptoms. So 
great is this danger, that most practitioners regard this mode of treatment 
as almost entirely inadmissible ; and indeed it must, we think, be conceded 
that it is quite inadmissible in cases of compression of the oesophagus by 
an aneurism, and in cases of malignant disease — especially those in which 
ulceration or sloughing has taken place. But there cannot, we think, be a 
doubt of the benefit which may accrue from the regulated use of the bougie 
in skilful hands, in cases of simple stricture. The dilator suggested by 
Dr. M. Mackenzie is well suited for such cases. The passage of the bougie 
has occasionally ruptured an abscess to which obstruction was due, and in 
this way cured the patient. When the ingestion of food is largely inter- 
fered with, and the patient shows manifest signs of starvation, the question 
as to whether he may be supplied with food by any other route than the 
oesophagus arises. The use of nutritive enemata is one of the methods 
which suggest themselves, and is often useful in prolonging life. Another 
method is that of laying open the stomach itself through the anterior 
abdominal wall, and feeding the patient through the artificial opening. 
Several such operations have been performed, and although the cases have 
not been very successful, the feasibility of the operation has been clearly 
demonstrated. 
37 



578 



DISEASES OF THE DIGESTIVE ORGANS. 



Section III. — DISEASES OF THE STOMACH, INTESTINES, 
AND PERITONEUM. 

I. INTRODUCTORY REMARKS. 

A. Anatomical relations. 

The surface of the abdomen is artificially divided into regions which are 
convenient in determining the relations of the organs situated within. This 
division is usually effected by drawing two horizontal lines — one above, 
from the lowest point to which the ribs descend on the one side to the 
corresponding point on the other side ; one below, between the anterior 
superior spines of the iliac bones ; and then intersecting them by two 
vertical lines drawn, one on either side, from the cartilage of the eighth 
rib above to the centre of Pou part's ligament below. Nine unequal spaces 
are thus mapped out ; of which the three occupying the median aspect of 
the abdomen are, from above downwards, the epigastrium or scrobiculus 
cordis, the umbilical region, and the hypogastrium ; and the three on 
either side are, in the same order, the hypochondrium, the lumbar region, 
and the iliac region. The hypochondriac and iliac regions are small and 
triangular; the lumbar extend round to the spine, occupying on either side 
the whole interval between the ribs and the crest of the ilium, and are, 
therefore, of considerable extent. 

The epigastric region is occupied mainly by the stomach, inclusive of 
its pyloric extremity, portions of the right and left lobes of the liver 
appearing above on either side of the ensiform cartilage; more deeply 
seated lie the hepatic vessels, pancreas, coeliac axis, and semilunar ganglia. 
The umbilical and hypogastric regions are occupied almost exclusively by 
the convolutions of the small intestine ; along the upper part passes the 
transverse colon, and into the lower part ascend the distended bladder and 
the gravid uterus. Deep in these regions lie the third portion of the duo- 
denum above, and the mesentery Avith its vessels and glands below. The 
right hypochondriac region contains the lower edge of the right lobe of 
the liver with the gall-bladder, and the hepatic flexure of the colon ; more 
deeply the first and second portions of the duodenum ; and more deeply 
still the upper part of the right kidney and the suprarenal capsule. The 
left hypochondrium is occupied by the lower portion of the spleen, the 
cardiac extremity of the stomach, the splenic flexure of the colon, and more 
deeply by the upper part of the left kidney and the suprarenal body. Each 
lumbar region is occupied by the convolutions of the small intestine, late- 
rally by the ascending or descending colon, and further back by the lower 
half of one of the kidneys. In the right iliac region is placed the ccecum, 
in the left the sigmoid flexure. 

B. Examination of the Abdomen. 

The direct examination of the abdomen in all cases of disease of the 
contained viscera, and in all affections attended with symptoms referable 
to these organs, should never be neglected. And in conducting such ex- 
aminations, and forming our opinions from them, we must always recollect, 
not only the normal positions of the parts within, but the facts that even 



EXAMINATION OF THE ABDOMEN. 



579 



in health many organs are liable to considerable changes of bulk and posi- 
tion, and that in disease such changes are often in the highest degree mis- 
leading. Apart from rectal, vaginal, and urethral examinations, which 
we shall not now enter upon, the methods of investigation include inspec- 
tion, palpation, percussion, and auscultation. 

1. Inspection Much may often be learned by simple inspection. The 

form of the abdomen in many diseases is no doubt entirely normal ; but it 
is often more or less importantly and characteristically modified. In cases 
of extreme emaciation, whether from starvation or any other cause, the 
surface becomes flattened or even concave ; and a somewhat similar retrac- 
tion of the parietes is frequently observed in cerebral disease, especially of 
children. On the other hand, the abdomen is often more prominent than 
natural. This condition may be due to fat in the parietes, or to anasarca ; 
in which case the general symmetry of the belly is maintained, but the 
umbilicus is usually deeply sunk. It may depend on distension of the 
stomach and bowels; when not unfrequently the abdominal walls (espe- 
cially if they be thin) are moulded in some degree to the alternate depres- 
sions and elevations of the subjacent organs. When distension is the 
consequence of ascitic accumulation, the belly (owing to the influence of 
gravitation) always has a tendency, as the patient lies on his back, to ex- 
pand laterally and to bulge in the flanks — a tendency, however, which often 
disappears when the accumulation becomes very large, and may be masked 
by coincident tympanites. Enlargement due to enlargement of solid organs, 
ta tumors, or to abscesses, is rarely symmetrical. The movements of the 
abdominal walls are often significant. In pericarditis and pleurisy, and 
especially in paralytic affections of the diaphragm, and peritonitis, with 
other inflammatory affections of the abdominal organs, the diaphragm be- 
comes inactive, and the surface of the belly remains quiescent during 
respiration. In cases of distension of the stomach or bowels, especially if 
it be due to any mechanical impediment to their action, the peristaltic 
movements of the dilated organs may often be distinctly seen and traced. 
It need scarcely be added that the movements of the foetus in the gravid 
uterus are distinctly visible. The condition of the parietes again may be 
of service to us. We may note the presence or absence of eruptions, or of 
dilated veins which generally accompany ascites, tumors, and obstructive 
disease of the portal vein, vena cava, or iliac veins. We may also observe 
whether they present circumscribed redness, brawniness, or swelling, such 
as indicates the pointing of an abscess or the extension of inflammation 
from below, or whether there be any cutaneous or subcutaneous tumor or 
an umbilical or any other hernia. Further, it may be remarked: not only 
that abdominal walls which have been the seat of much dropsical effusion 
or fatty accumulation fall into wrinkles when the fluid or fat disappears, 
but also that when once the abdomen has been largely distended (whether 
by pregnancy, ascites, or any other condition) they are liable to present 
those atrophic lines which habitually follow childbirth. 

2. Palpation — By manual or tactile examination we distinguish the 
different degrees of hardness, softness, resistance, and elasticity of the 
abdominal walls and subjacent parts, and can thus often determine the 
size, shape, quality, and relations of tumors. Moreover we may recognize 
the fluctuation due to the presence of fluid, the pulsation of arteries and 
aneurisms, the thrill or crepitation resulting from inflammatory deposit, 
and the peristaltic movements of the stomach and bowels. 

When the parietes are flaccid, especially if they be at the same time 



580 



DISEASES OF THE DIGESTIVE ORGANS. 



thin, we may sometimes by careful manipulation map out the form of the 
kidneys and other deep-seated solid organs. Indeed under such circum- 
stances the kidneys have been mistaken for tumors and the abdominal 
aorta (especially that part of it which lies on the promontory of the sacrum) 
for an aneurism. When the walls are rigid (as in fact they are only too 
apt to be in those cases where examination is most needed) it is often ex- 
ceedingly difficult to determine the condition of parts within. Moreover, 
portions of the rigid recti muscles are then very liable to be mistaken for 
tumors. In this case the patient should be made to lie on his back with 
elevated shoulders and knees, and heels pressed into the bed ; and then 
the physician with warm hand or hands should press quietly but firmly on 
the abdomen, making the patient from time to time draw a deep breath. 
By such means and taking constant advantage of each momentary relaxa- 
tion, he may often in a short time overcome the muscular rigidity, and 
learn all that is necessary with regard to the subjacent organs. If these 
measures fail, the patient must be examined under the influence of anaes- 
thetics. 

The source of a tumor is in great measure distinguishable by its site and 
relations to the abdominal organs. We need not particularize the different 
localities in which we should expect to discover tumors of the liver, spleen, 
kidneys, or other viscera. We may, however, point out the importance 
and mode of determining whether a tumor be in the abdominal walls or 
adherent to them, or spring from the back of the cavity, or be connected 
with some of the movable parts within. A tumor of the walls necessarily 
rises and sinks with the walls during respiration. A tumor connected 
with the liver, spleen, stomach, bowels, or omentum ascends and descends 
with the movements of the diaphragm, and, if unattached to the abdominal 
walls in front, can be distinctly felt to glide under them. This locomotion 
dependent on the diaphragm is of course most obvious in the case of tumors 
resting against the diaphragm or near it. Tumors springing from the 
kidneys or back of the abdomen are usually fixed, or, if movable at all, 
generally slightly in the transverse direction. Many growths connected 
with the stomach, bowels, ovaries, and peritoneum are freely movable, 
either under the hand of the examiner or with change of position. The 
form, size, and consistence of tumors, and the presence or absence of fluc- 
tuation in them, are points of importance. 

The presence of fluid in the peritoneal cavity is generally attended with 
the sense of fluctuation. This is best obtained by pressing the left hand 
firmly and flat upon the abdomen, and then giving a sharp tap or fillip 
with the fingers of the opposite hand. It is most marked when the fluid 
is abundant, and the walls thin and tense. The sense of fluctuation com- 
prises two elements : the one an instantaneous impulse conveyed through 
the fluid and not generally very perceptible ; the other a wave which 
travels over its surface and involves the abdominal parietes. The latter 
is what is usually meant by the term ; but it must be observed that it (or 
something very like it) is occasionally observed in flaccid abdomens free 
from dropsy, and that it may be arrested or annulled by pressure made on 
the abdomen between the finger which percusses and the hand which 
receives the impression. In connection with the presence of ascites it may 
be observed : that a layer of fluid, varying say from half to one inch in 
thickness, often intervenes between the upper surface of an enlarged liver 
and the anterior abdominal walls; and that the presence of the liver may 
then often be readily detected by pressing the finger perpendicularly with 



GASTRITIS. 



581 



suddenness and force, and thus displacing the fluid and coming into sudden 
contact with the surface of the solid organ. 

3. Percussion On percussing the abdomen we obtain, as a general 

rule, resonance or dulness, according as we operate over the stomach and 
bowels or over solid organs. Abdominal resonance is higher pitched and 
more musical than that elicited over the lungs. It is also much more 
variable in health, owing to the varying distension of the different parts 
of the alimentary canal. The percussion note is of course higher according 
as the tube percussed is narrower; hence deeper notes are usually obtained 
over the stomach than over the colon, and over the colon than over the 
small intestine. But in morbid states (which need not here be specified) 
the stomach may contract so as to yield a note like that of the healthy 
ileum, or the ileum or colon may become so much dilated, as to furnish a 
note like that usually belonging to the stomach. Although percussion for 
the most part gives a dull sound over solid organs, it is an important fact 
that distinct resonance may often be elicited over the thin edge of the liver, 
due to the liver and abdominal parietes vibrating together over the sub- 
jacent stomach. Occasionally also such resonance may be elicited over 
the spleen. The determination of the exact distribution of resonance and 
dulness is often very important in reference to the diagnosis of abdominal 
tumors — the course, for example, which the ascending, descending, or 
transverse colon may take in relation to a tumor, often deciding for us 
whether it arises in the kidney, liver, retro-peritoneal glands, or some 
other part. It is necessary, therefore, to bear in mind that a line of bowel 
lying superficially to a solid mass may be readily overlooked, if care be not 
taken in the examination ; for if, as in ordinary percussion, the finger of 
the left hand be pressed upon the part to be percussed, the bowel may 
be readily flattened under its influence, and dulness result. In all such 
cases, and indeed generally in abdominal percussion, when we are anxious 
to make a minute and critical examination of the condition of parts lying 
immediately under the walls, it is best to percuss by simply filliping the 
surface with the nail of the right forefinger. Of the peculiar prolonged 
thrill often observed on percussion over an hydatid tumor we shall speak 
hereafter. 

4. Auscultation — Of course gurgling and musical sounds of all sorts 
may be heard with the stethoscope over the stomach and alimentary canal, 
but little or nothing is to be learned from them. Besides these, arterial 
murmurs due to the presence of aneurism, or to the pressure of tumors or 
of the stethoscope, venous murmurs in connection with the gravid uterus, 
abdominal tumors, or dilated veins, the beats of the foetal heart, and friction 
sounds in connection with hepatic or splenic peritonitis, may be met with 
under different circumstances. 



II. GASTRITIS. 

Causation. — Acute gastritis in its severest form is exceedingly rare, 
unless as the result of the direct application of irritant or corrosive sub- 
stances to the mucous surface of the stomach. Its milder varieties, on the 
other hand, are very common at all ages and in both sexes, and from their 
mildness not unfrequently escape notice. The causes of gastritis are 



582 



DISEASES OF THE DIGESTIVE ORGANS. 



various ; and include the ingestion of irritant or corrosive substances, the 
use of food which is ill-masticated, too abundant, or unwholesome — there- 
fore, excess in eating and the abuse of alcohol — exposure to cold, and other 
atmospheric influences. Among predisposing causes must be enumerated 
constitutional debility, tuberculosis, various acute febrile complaints, heart, 
lung, and renal disease, and cirrhosis of the liver. 

Morbid anatomy — Slight inflammation, though obvious enough when 
seen, as in the case of Alexis St. Martin, during life, often leaves little 
trace of its existence after death. It is indicated by patchy congestion ; 
enlargement of the epithelial cells, with a more or less cloudy condition of 
their protoplasm, and the appearance of fat granules within them ; similar 
changes in the cells of the mucous glands ; and hypertrophy of the lymph- 
atic tissue. These conditions involve some degree of thickening and 
softening of the mucous membrane; and are attended with the formation of 
a greater or less abundance of ropy alkaline mucus, and diminished secre- 
tion of the true gastric juice. But these are not the only changes. Fre- 
quently, small extravasations of blood take place here and there into the 
substance of the mucous membrane, and small quantities of blood may even 
escape into the cavity of the stomach ; and sometimes erosions, shallow 
ulcers, or superficial sloughs are developed. Some of the latter appear to 
be connected with previous hemorrhagic infiltration, if not dependent on it. 
When inflammation is due to the action of corrosive substances, the morbid 
appearances are determined largely by their several peculiarities of chemical 
action. There is usually, however, intense congestion, with more or less 
extensive destruction of the mucous membrane. Inflammation involving 
the whole thickness of the gastric wails is rare as an idiopathic affection. 
In these cases they are swollen in their entire thickness, sometimes infil- 
trated with simple inflammatory exudation, or pus, sometimes presenting 
scattered abscesses. 

The morbid anatomy of chronic inflammation differs little from that of 
the acute affection. There is generally, however, less congestion and more 
degeneration. The mucous membrane is usually thicker than normal, 
pale, and comparatively tough. It may present extravasations of blood, 
and excoriations or ulcers. But more frequently it is studded here and 
there with black or slate-colored spots, which are the pigmental remains of 
old extravasations or congestions ; and with opaque white patches, which 
are due to fatty degeneration of the epithelial contents of groups of gland 
tubes, and even of the corpuscles of the connective tissue between them, 
and are often associated with atrophy and shrivelling of the glands, and a 
tendency to the formation of cysts. 

Symptoms and progress 1. In severe idiopathic gastritis, as also in 

gastritis due to irritant poisoning, the symptoms are of an exceedingly 
violent character. The patient suffers from intense burning and shooting 
pain in the epigastrium and lower part of the chest in front, and between . 
the shoulders, attended with rigidity and retraction of the abdominal 
muscles ; extreme tenderness on pressure in the epigastric region ; aggrava- 
tion of pain on drawing a deep breath, with consequent shallow respiration; 
nausea, retching, and vomiting, not only after everything that is taken 
into the stomach, but even when the organ is empty ; total loss of appetite ; 
intense thirst ; and collapse, marked by extreme feebleness of pulse, cold- 
ness and pallor of surface, cold perspirations, and tendency to faint. 
Besides these symptoms, distressing hiccough usually supervenes, and the 
bowels may become loose. The character of the vomit depends on circum- 



GASTRITIS. 



583 



stances. Generally, however, it comprises mucus (which is often mingled 
with, more or less, altered blood), and bile, and of* course such matters as 
have been swallowed. The supervention of collapse, which forms so 
marked a phenomenon of the affection, is preceded by heat of skin and 
other febrile symptoms which, however, soon subside. When the case 
ends fatally, death is mostly due to prostration; and the patient usually 
retains consciousness to the last. The date at which death supervenes 
varies generally between one and six or seven days. If recovery take 
place, it is usually protracted. 

2. In the commoner and milder forms of acute gastritis, the symptoms 
are essentially the same as those which characterize the graver attacks : 
namely, heat or aching in the region of the stomach ; tenderness on pres- 
sure in the epigastrium, with more or less rigidity of the abdominal mus- 
cles, especially the recti, and the endeavor to obtain ease by bending the 
body forwards, and restraining the action of the diaphragm ; irritability 
of stomach, with tendency to eructation and to reject by vomiting what- 
ever is taken into it ; anorexia, thirst, and febrile disturbance. Besides 
which, the tongue is usually coated, and there is more or less headache, 
with intolerance of light, depression of spirits, and disturbed sleep. The 
symptoms are subject, however, to great variety, and even the most char- 
acteristic of them may be absent. 

Pain in the stomach may fail wholly, or exist as a mere sensation of 
warmth, or it may be replaced by a violent craving for food. Ingestion 
of food, however, in such cases does not usually give the anticipated relief, 
and often brings on pain and induces vomiting. Irritability of the stomach 
may be extreme ; on the other hand, it may be indicated by frequent 
eructations only. Under any circumstances, however, the taking of food 
or drink, except in moderation, will probably insure its rejection and 
bring on epigastric pain. The vomit consists of ropy and tenacious mucus, 
mixed with matters which have been swallowed, and (if the vomiting have 
been prolonged) with bile. Blood, in small quantities, may be contained 
in it. The breath is usually febrile or offensive, and not unfrequently 
fetid. The eructations occasionally have the odor of sulphuretted hydro- 
gen. Thirst is generally a marked feature, but now and then is wholly 
absent. The temperature is usually elevated above the normal, but rarely 
exceeds 100° ; it presents variations during the day, and, for the most 
part, an afternoon or evening rise. The patient often feels chilly, and 
even has distinct rigors. The skin is hot, but disposed to be moist at 
times. In most cases the tongue becomes early covered with a thick 
whitish or brownish creamy fur, through which the congested fungiform 
papillae protrude ; but it may be abnormally red and clean, and then often 
dry, glazed and fissured. In some cases it is little changed from the normal. 
Taste is usually perverted ; and there is often a sensation of bitterness or 
a metallic flavor. Headache is usually very severe, of an aching or throb- 
bing character, and limited to some particular region. In some cases it is 
difficult, if not impossible, to distinguish it from that of megrim. Chiefly 
when the headache is frontal there is disturbance of vision and photo- 
phobia. The patient is commonly more or less irritable and restless, yet 
depressed ; he is often drowsy, yet unable to obtain refreshing sleep — his 
rest being disturbed by dreams. Further, the action of the heart fre- 
quently becomes enfeebled, the pulse quick and small, the extremities 
cold ; and there may be palpitation, faintness, dyspnoea, and confusion of 
mind. Associated with gastric inflammation there is very often more or 



584 



DISEASES OF THE DIGESTIVE ORGANS. 



less disturbance of the bowels ; generally flatulence, and either constipa- 
tion, griping and purging, or irregularity of action. These disturbances, 
however, are in many cases due to concurrent inflammatory implication of 
the mucous membrane of the bowels. 

In some cases the symptoms of the milder forms of acute gastritis 
scarcely differ from those of enteric fever ; while in some they are little 
more than such as constitute an ordinary sick headache ; and in others 
amount collectively only to that vague sense of illness to which the term 
* malaise' is commonly applied. In young children, drowsiness and other 
cerebral phenomena, such as coma and convulsions, are not unfrequent 
accompaniments of the gastric disorder ; and it is among them that diar- 
rhoea is chiefly common. When gastritis arises in the course of of her 
affections, its symptoms are liable to be overlooked. 

3. The symptoms of chronic gastritis necessarily present a considerable 
resemblance to those of the acute disorder, but are on the whole more 
vague, and merge into those included in the collective term dyspepsia. 
The patient, moreover, is in many cases liable to remissions, during which 
he appears to enjoy comparatively good health. In other cases he ails 
continuously. Febrile symptoms, on the whole, are slight, and often alto- 
gether absent ; thirst, anorexia, vomiting, and uneasiness or pain in the 
epigastrium and between the shoulders, are all more variable and generally 
less severe than in the acute disorder ; vomiting, however, of an abund- 
ance of glairy mucus is often a characteristic phenomenon ; the tongue 
varies in its condition, as it does in the acute affection, and often gets fur- 
rowed or intersected with Assure-like depressions ; the breath is offensive ; 
the bowels usually are confined ; and the patient becomes restless, irritable, 
nervous, and hypochondriacal, but rarely suffers so severely from headache 
as those who labor under the more acute disorder. With its continuance 
emaciation and debility come on, with defective circulation, coldness of 
extremities, and tendency to palpitation and faintness. Numberless other 
symptoms and consequences, of more or less importance, are commonly, 
and no doubt in the main correctly, attributed to chronic gastritis. For 
the most part, however, they constitute no essential part of it, and are 
connected with it only as they are with many other affections in which the 
processes of nutrition are profoundly involved. 

Treatment — 1. In the treatment of severe acute gastritis, local measures 
are of great importance. Leeches — twelve, twenty, or more — may be ap- 
plied to the epigastrium ; or warm fomentations may be employed, or ice, 
or mustard poultices and other counter-irritants. Which of these appli- 
cations should be selected must depend on the severity, or stage, or other 
conditions affecting the case. The irritability of the stomach renders the 
introduction of food and medicine in bulk into that organ impossible or 
undesirable. A little ice may be sucked, or ice-cold water or milk sipped ; 
and opiates in large doses should be administered. If given by the mouth 
they should be in the form of pill, powder, solution of morphia, or undilute 
liquid extract of opium. The association of opium with bismuth or mag- 
nesia is often very efficacious. The best mode, however, of introducing 
opiates is undoubtedly by subcutaneous injection. 

2. In less severe cases, local bleeding need scarcely ever be resorted to, 
but warm fomentations and counter-irritants are of benefit. Here also 
the use of ice, or minute quantities of ice-cold water, often affords much 
relief. And generally it is desirable to avoid, as far as possible, the ad- 
ministration of food or drink until irritability and pain have in great mea- 



ENTERITIS. 



585 



sure subsided. In some cases, opium is of great value ; but generally it 
is not called for. Bismuth, magnesia, lime-water, nitrate of silver, effer- 
vescent alkalies, and hydrocyanic acid are often beneficial. When consti- 
pation is present, or there is evidence of implication of the bowels, purga- 
tives are valuable, especially perhaps castor-oil, calomel in combination 
with rhubarb, and enemata. When food is given it should be of light 
quality and easily digestible. Milk and farinaceous substances are most 
suitable. Later on, animal broths, fish, and chicken may be allowed. 
Alcoholic drinks are not desirable, unless there be marked tendency to 
depression or collapse. Under similar circumstances, ammonia is often 
serviceable. 

3. Chronic gastritis usually requires much attention to hygienic con- 
ditions. The patient should be enjoined to take moderate and regular 
exercise, to seek change of air and scene, to keep good hours, and gener- 
ally to adopt such a mode of life and such habits as are conducive to 
health. The diet should be strictly regulated, but it is difficult to lay 
down definite rules with respect to such regulation. The patient's own 
experience is usually an important, if not the best, guide. He should 
carefully avoid all those articles of diet which he has found to be prejudi- 
cial to him, however wholesome theoretically we may suppose them to be. 
Milk, well-cooked farinaceous substances, fish, fowl, and well-roasted 
mutton and beef in small quantities are probably on the whole the most 
suitable. Salted meats, rich and highly-seasoned dishes, pork and veal, 
should be especially eschewed. Tea often disagrees. Alcohol is seldom 
beneficial, and should only be used sparingly and in a dilute form. The 
particular beverage to be employed must depend on circumstances. As 
to medicinal treatment, the bowels should be regulated by occasional lax- 
atives or mild purgatives ; and tonics — especially quinine or nux vomica 
in combination with hydrochloric acid, and calumba or gentian associated 
with alkalies and rhubarb, or bismuth — effervescing medicines, lime, 
silver, zinc, hydrocyanic acid, belladonna, opium, and pepsine, have all 
been found more or less useful under different circumstances and in differ- 
ent cases. 



III. ENTERITIS. 

Causation — Acute inflammation of the bowels, like the corresponding 
affection of the stomach, presents every degree of severity. The simplest, 
or catarrhal, form may be caused by the local action of irritating ingesta, 
or those external conditions which are commonly instrumental in excit- 
ing idiopathic inflammations. Young children, mainly about the time of 
teething, are specially liable to it ; and it is said to be common in scarla- 
tina and other specific fevers. Occasionally, it becomes chronic, and is 
then apt to be associated with morbid states of other organs, to which, 
indeed, it is often secondary. The stomach especially, under these cir- 
cumstances, is frequently the seat of some chronic morbid process. But 
enteritis, in the usual sense of the term — the 1 phlegmonous enteritis' of 
Cullen — is rarely of idiopathic origin ; it is generally the result of some 
mechanical injury, and thus complicates strangulated hernia, intussuscep- 
tion, the impaction of gall-stones and other foreign bodies, and intestinal 
stricture. 



586 



DISEASES OF THE DIGESTIVE ORGANS. 



Morbid anatomy. — 1. Acute catarrhal inflammation of the bowel is 
characterized anatomically by congestion, tumefaction, and dryness of the 
mucous membrane, speedily followed by the more or less abundant secre- 
tion of mucus, which is ropy or watery, irritating, and sometimes mixed 
with blood. When the inflammation assumes a chronic form, the mucous 
membrane becomes condensed and hardened, congested, and studded 
with black pigmentary deposits. There is often atrophy of the Lieber- 
kiihnian follicles, with granular or fatty degeneration of their epithelial 
contents ; and atrophy, or even enlargement, of the solitary and agminated 
glands. 

2. Occasionally, under conditions which are not well understood, mem- 
branous pellicles in patches arise, especially in the large intestine, in 
connection with chronic enteritis. They consist of corpuscular elements 
cemented together by a coagulable exudation, and are for the most part 
prolonged by rootlets into the Lieberkiihnian follicles. Their development 
usually is attended with much greater congestion and thickening of the 
mucous membrane than is the simple catarrhal affection, and not unfre- 
quently hemorrhage, suppuration, or gangrene ensues. In the large intes- 
tine the pellicular inflammatory patches are sometimes linear, sometimes 
irregularly polygonal or stellate, and occupy, for the most part, the promi- 
nent ridges of the mucous membrane, especially the edges of the inter- 
saccular constrictions. In some cases, while still occupying the more 
prominent parts, they form a coarse irregular network over large tracts of 
surface ; in other cases they coalesce into uniform patches of considerable 
extent. In the small intestine pellicular inflammation may be found, 
either affecting only the free edges of the valvulae conniventes, or spread 
over large arese. Cases sometimes come under observation in which 
patients pass per anum shreds of false membrane, or even membranous 
casts of the bowel, of soft texture, various thickness, and a dirty greenish 
or brown hue. This discharge is generally, if not always, the consequence 
of dysenteric ulceration. 

3. The morbid changes discoverable after death in phlegmonous enteri- 
tis are such as are produced by intense inflammation of a limited tract of 
bowel. The affected part, which is mostly in the small intestine, and may 
vary in length from an inch or two to two or three feet, is as a rule much 
dilated. Its serous surface presents a general dusky red, slaty, or purplish- 
black color, due to the condition of the parts internal to it ; it is marked, 
too, by lines or patches of more or less intense superficial congestion, may 
present blotches of subserous extravasation, and is often covered to a 
greater or less extent with adherent lymph. Its mucous and submucous 
tissues are mostly somewhat thickened and softened, sometimes only mode- 
rately congested but presenting spots and streaks of extravasation, some- 
times black from combined congestion and escape of blood, sometimes pale 
and infiltrated with lymph or pus, sometimes distinctly gangrenous. And 
its middle coat, sharing in these changes, is also more or less swollen and 
soft, congested or oedematous, or the seat of some form of inflammatory 
exudation. The inflamed tract usually presents fairly well-defined limits, 
terminating abruptly below in pale and healthy but contracted and nearly 
empty bowel, above in bowel which may also be healthy, but is dilated 
like the diseased portion, and filled like it with fecal contents. The dis- 
eased intestine frequently contains, in addition to fecal matter, more or 
less sanguineous exudation, or a thick pitchy fetid fluid ; and traces of the 
same may often be discovered in the contracted bowel below. 



ENTERITIS. 



587 



Symptoms and progress — 1. Catarrh may affect the lower bowel only, 
causing mild dysenteric symptoms ; but very often it begins in the upper 
bowel, or stomach, and spreading thence downwards gradually traverses 
the whole length of the intestinal canal, causing in its progress more or 
less uneasiness, aching, and griping — frequently attended with nausea and 
sickness while the inflammation is still high up, with diarrhcea and expul- 
sive pains and efforts when it reaches the large intestine. The tongue 
generally is more or less furred and dry, the breath offensive, and the 
appetite impaired ; but these symptoms vary, and are often absent, espe- 
cially when the large intestine alone is affected. Some degree of general 
febrile disturbance, indicated by heat and dryness of skin, sense of chilli- 
ness, increased frequency of pulse, lassitude and headache, is usually 
attendant on the local disorder. In children, in whom inflammatory 
affection of the gastro-intestinal mucous membrane is sometimes associated 
with aphthae, the disease not unfrequently causes serious result and death, 
either from the debility which follows persistent diarrhoea and vomiting, or 
from the supervention of convulsions and coma. It is obvious that the 
symptoms of this disorder differ but little from those assigned to the com- 
moner varieties of gastritis ; but gastritis and enteritis are usually associated 
more or less intimately, and their respective characteristics consequently 
get intermingled. 

The symptoms of the chronic disorder vary greatly, but- may be briefly 
summarized as combining, in various proportions, imperfect digestion of 
the alimentary matters received into the intestine, excessive secretion of 
more or less watery mucus, increased peristalsis with griping pains, loose- 
ness of the bowels, discharge of watery, yeasty, or otherwise unhealthy 
and offensive evacuations, and innutrition from imperfect absorption of 
food. 

2. The symptoms which attend enteritis with the formation of mem- 
branous pellicles are not special; they vary, on the one hand, between 
those of diarrhoea and dysentery, and on the other hand between those of 
mere colic and typical enteritis ; moreover the affection is often overlooked 
from the fact that it is apt 'to occur as a complication of the later stages of 
many grave disorders, as, for example, acute pneumonia, Bright's disease, 
cirrhosis of the liver, and cerebral affections. 

3. The symptoms of phlegmonous enteritis are, even when the disease 
is unattended with any of the mechanical lesions which so often complicate 
it, liable to considerable variety — the variations depending mainly on the 
degree of inflammation and its extent, and on the situation of the affected 
portion of bowel. The principal factors in producing the characteristic 
symptoms are inflammation, on which the various febrile phenomena de- 
pend ; and paralysis of the inflamed tract of bowel, which permits of its 
passive dilatation by the accumulation of contents, opposes a more or less 
complete bar to their transit, and thus induces, on the one hand constipa- 
tion, on the other vomiting. 

Heat of the skin, rigors, and quickness and hardness of pulse, not un- 
frequently mark the onset of the attack ; but the invasion is in many 
cases insidious and unattended witli obvious febrile symptoms. There is 
mostly some dryness and clamminess of the mouth, if not absolute thirst ; 
and the tongue, which is occasionally pretty clean at the beginning, gener- 
ally soon gets thickly coated, and ultimately dry. 

A special feature of enteritis is the association of the abdominal pain 
and tenderness of peritonitis with the tormina of colic. Pain and tender- 



588 



DISEASES OF THE DIGESTIVE ORGANS. 



ness are certainly present in most cases, at least in the beginning, and in 
dependence upon them the dorsal decubitus so characteristic of peritoneal 
inflammation. They are sometimes, however, scarcely appreciable from 
first to last, and generally subside in the progress of the case. It can 
readily be understood that, when the peritoneal surface is largely involved, 
pain and tenderness will generally be proportionately severe ; that when 
an extensive length of bowel is affected there will be correspondingly ex- 
tensive uneasiness and tenderness ; and that when, as sometimes happens, 
the serous surface is not inflamed, or the affected portion of bowel is small, 
pain and tenderness may be not only limited in extent, but no greater 
than we find them in colic or simple ulceration of the mucous membrane. 
It may be observed that limited pain and tenderness are very commonly 
referred to the region of the umbilicus. Tormina are often at the onset 
very agonizing, and are then probably due in some measure to the spas- 
modic movements of the inflamed bowel ; but they continue after paralysis 
is established, in consequence of the violent but ineffectual efforts of the 
bowel above to overcome the impediment which the disease produces. 
But tormina are sometimes scarcely recognizable, and frequently, like pain, 
cease comparatively early. 

Constipation and vomiting are among the most important symptoms of 
enteritis. Constipation, in the uncomplicated affection, is due simply to 
want of contractile power in the inflamed length of gut. It is therefore 
not necessarily absolute ; there is no reason why the attack should com- 
mence with constipation, or why the bowel below the seat of disease should 
not empty itself in the progress of the case, or even why a certain amount 
of fecal matter should not slip through the inflamed region into the healtheir 
bowel below. Nevertheless the inflamed bowel is really a substantial im- 
pediment, constipation is a striking incident in the disease, and purgatives 
as a rule fail to produce a purgative effect. The vomiting of enteritis is 
probably at the commencement mainly functional, but ultimately it is due, 
like the constipation, to intestinal obstruction. In the first instance, no 
matter where the obstruction, the vojnited matters are merely the secre- 
tions of the stomach mixed with alimentary substances ; but soon bile is 
added, and before long glairy mucus and bile alone are discharged. Then 
the eructations become fetid, and the fluid brought up is turbid and brown- 
ish, and by degrees comes to resemble the contents of the lower part of the 
small intestine ; but it becomes fetid also — far more fetid, indeed, than 
the contents of a healthy bowel ever are. This discharge of ' stercora- 
ceous' matter by the mouth is due, not to inverted paristaltic action, but 
to the fact that the general contents of the distended bowel are gradually 
churned up, as it were, and intermingled, by the constantly recurring 
peristaltic movements of their muscular walls. 

Hiccough is often a distressing symptom. Tympanites is probably 
always present ; slight at the beginning, but increasing as the case pro- 
gresses until the belly becomes greatly distended, tense, and drum-like. 
It is due mainly to the distension of the inflamed bowel, and that above 
it, with fecal matter and flatus. But now and then it is connected with 
rupture of the distended intestine and escape of gas into the peritoneal 
cavity. 

The pulse usually is accelerated and hard at the beginning, but varies 
in different cases in frequency, volume, and strength, and is sometimes 
nearly normal in character ; but as the fatal issue approaches it gets more 
and more feeble, and sometimes at length wholly imperceptible at the 



ENTERITIS. 



589 



wrist. It generally also becomes quicker, but sometimes slower, and not 
unfrequently irregular. 

The temperature of the skin is usually in the first instance more or less 
elevated, and the surface dry; but even then sweats are apt to break out, 
especially during the colicky paroxysms ; subsequently the temperature 
falls, the extremities and face get cold and pale or livid, with sometimes a 
slight tinge of jaundice, and all parts of the surface bathed in profuse cold 
sweat. The expression is generally indicative of anxiety and distress, 
and the features pinched and shrivelled. 

The patient as a rule retains his senses throughout his illness, and even 
up to the moment of death ; but this event is often preceded by a period 
of quiescence or lethargy, and occasionally by slight rambling and partial 
unconsciousness. There is generally almost complete suppression of urine. 

Enteritis in its most violent form is an extremely dangerous and indeed 
generally a very rapidly fatal malady. Death may occur within twenty- 
four hours, and is rarely delayed beyond a week. 

Treatment The treatment of the milder forms of enteritis is so inti- 
mately connected on the one hand with that of inflammatory affections of 
the stomach, and on the other with that of diarrhoea and dysentery, that 
the reader may be safely referred to the articles on those subjects for all 
necessary details. As regards the treatment of the more severe forms of 
the disease, two main principles seem to be fairly well established : — 
namely, first, to relieve the pain, and prevent as far as may be all move- 
ments of the bowels ; second, to avoid every attempt (at least until all 
grave symptoms have ceased) to force the bowels by the administration 
of purgatives. Constipation, lasting for a few days, or even prolonged for 
a week or two, in itself is generally a matter of very little consequence ; 
it is, however, a matter of very serious consequence to intensify the pain 
from which patients are already suffering, to fret and irritate inflamed 
organs, and to subject to unwonted violence bowels unnaturally soft, en- 
feebled, and ready to undergo laceration. Clearly if patients are to get 
well, their recovery must in the first instance depend on the recovery by 
the diseased bowels of their healthy tone and capability of peristaltic action, 
and on the relief of pain and irritation. For these purposes, opium in 
large and frequent doses is generally our most valuable resource. No ab- 
solute rule can be laid down with regard to the quantity of this drug to 
be given at one time, or the frequency with which the dose should be re- 
peated ; the patient should, however, be got well under its influence and 
kept under its influence. For many reasons it is best administered by 
subcutaneous injection. 

But our treatment need not be limited to the use of opium. The ab- 
straction of blood is often of the greatest value. This is most efficacious 
early in the disease, and may be effected either by the opening of a vein 
in the arm, or by the application of ten, twenty, or thirty leeches to the 
surface of the belly. Warm but light applications, and hot fomentations, 
generally soothe; and sometimes mustard plasters and similar mild counter- 
irritants give relief. In the same way enemata of warm water or gruel 
are at times useful. To relieve nausea and vomiting, ice, hydrocyanic 
acid, alkalies, lime-water, bismuth, carminatives, and the like may be 
tried, and may be of much efficacy ; but, when the vomiting is simply the 
consequence of over-distension of the bowels, as it sometimes is late in the 
disease, such remedies necessarily fail. The extreme prostration which 
so early manifests itself is a strong indication of the need of food and 



590 



DISEASES OF THE DIGESTIVE ORGANS. 



stimulants ; but their exhibition by the mouth tends to increase distension, 
already probably painful, and to promote sickness; and under such circum- 
stances they are little likely to be absorbed. It is obvious, indeed, that 
alimentary matters, if given by the mouth, must be given in very small 
quantities, and in a form suitable for their ready absorption. They are 
best administered in the form of enema. 



IV. ULCERATION OF THE STOMACH. 

Causation The occurrence of excoriation or superficial ulceration in 

the course of ordinary gastritis has already been referred to. Such lesions 
have rarely, however, any special importance, and as a rule speedily undergo 
spontaneous cure. But the stomach is also liable to become the seat of 
ulcers, which tend to spread widely and deeply, are productive of serious 
symptoms and sometimes of death, and the origin of which is to some 
extent enshrouded in mystery. These ulcers are seldom observed pre- 
viously to the age of ten or fifteen, but subsequently to that period they 
seem to increase in frequency with advancing life, not, indeed, absolutely, 
but in relation to the numbers of persons living at each successive period. 
They appear to be two or three times more common in females than in 
males. They are often associated with amenorrhcea and anasmia, or chlo- 
rosis, and in both sexes (but more especially in men) with the cachexias 
which follow from habits of drinking and dissipation and from syphilis. 
It is possible that these conditions of the system may be the actual causes 
of the ulceration ; it is more probable, however, that they tend to promote 
the spread and retard the healing of ulcers which have begun in the first 
instance independently of them. Virchow considers that ulcers originate 
mainly in affections of the vessels connected with the diseased area?, espe- 
cially embolism or degenerative change in the arteries, attended with arrest 
of circulation and necrosis, or obstruction of branches of the portal system 
of veins followed by interstitial hemorrhage. But it seems not improbable 
that the superficial ulcers which form in gastritis, and which as a rule 
readily heal, may under certain circumstances remain open, and be irri- 
tated into active enlargement. The progressive spread, and unwillingness 
to heal, of gastric ulcers, are readily explained by the constant irritation 
to which they are subjected by the ingestion of food, the pouring out of 
gastric juice, and the movements of the stomach in digestion. 

Morbid anatomy — Gastric ulcers vary in size from that of a four-penny- 
piece up to that of the palm of the hand. The smaller ones are usually 
circular or oval in shape ; the larger are more or less irregular, either from 
being formed by the coalescence of several smaller ulcers, or in conse- 
quence of irregular extension. When small an ulcer usually appears as 
if it had been made by punching out a bit of the mucous membrane. Its 
edges are more or less perpendicular ; and the tissues entering into their 
formation are infiltrated, indurated, and probably thickened to some little 
distance around. Its floor may be smooth, flocculent, or even superficially 
gangrenous ; and may be formed, according to the depth to which the 
ulcer has reached, by either the submucous tissue, the muscular coat, or 
simply the serous membrane. In an ulcer of large size the tissues which 
surround it are usually considerably thickened and indurated from inflam- 



ULCERATION OF THE STOMACH. 



591 



matory overgrowth, and often much congested ; the edges which are 
specially thickened, usually slope downwards to the floor of the ulcer, 
which thus becomes smaller than the superficial area of ulceration ; some- 
times, however, they are perpendicular ; sometimes undermined, and over- 
hanging. The floor of a large ulcer may be formed like that of a small 
one by any of the gastric tunics except the mucous membrane itself ; but 
it may be formed also by the substance of the liver, pancreas, or any other 
organ or tissue which has become adherent to the stomach, and involved 
in the progress of the ulceration. The floor may be smooth, irregular and 
flocculent ; or sloughy, or may present granulation-like bodies due to the 
projection of the lobules of the eroded pancreas. 

Gastric ulcers not unfrequently cicatrize. The surrounding thickening 
then diminishes, the sloping edges become undistinguishable, on the one 
side from the contiguous mucous membrane, on the other from the floor of 
the ulcer. The ulcerated surface contracts, radiating puckers form, and 
the central raw area grows smaller and smaller, and at length heals. The 
result is an opaque, whitish, smooth, tough, depressed area, surrounded by 
more or less obvious radiating folds of mucous membrane, and often at- 
tended with marked and it may be serious deformity of the stomach. It 
is not uncommon to find ulcers partly healed, or cicatrizing at one part 
while undergoing extension elsewhere. 

Unfortunately gastric ulcers do not always heal. In many cases they 
remain quiescent ; in many they slowly extend ; in many they end in 
perforation. Perforation sometimes takes place at once into the peri* 
toneum ; but sometimes the base of the ulcer previous to perforation be- 
comes adherent to some neighboring part, so that, while extravasation of 
the contents of the stomach into the peritoneal cavity is prevented, a com- 
munication becomes established with the transverse colon, or small intes- 
tine, with the pleura or lung through the diaphragm, or with the external 
air through the abdominal parietes. In other cases some artery— the 
splenic, coronary, gastro-epiploic, or one of their branches — or even the 
hepatic artery, or portal vein, becomes eroded and profuse hemorrhage 
ensues. 

Gastric ulcers are usually solitary, but occasionally two, three, or more 
are present at the same time. They may occur at any part of the stomach ; 
but are more frequent in the pyloric than in the cardiac half, in connection 
with the posterior than the anterior wall of the organ, and in the neigh- 
borhood of the smaller than in that of the larger curvature. Perforation 
is believed to be relatively more frequent in females than in males ; and is 
a not uncommon termination of ulcer, especially in young women. 

Symptoms and progress — The symptoms which attend gastric ulcer 
present much variety. In a few cases the disease proves fatal by perfora- 
tion or hemorrhage without having ever been attended with symptoms to 
attract attention to the stomach as the seat of disease. In most cases, 
however, the patient suffers from dyspeptic phenomena, of which the most 
common and characteristic are pain, vomiting, and hsematemesis. As 
ulcer of the stomach is mainly a chronic disease, so the symptoms to which 
it gives rise generally assume a chronic character. They creep on for the 
most part gradually, probably sometimes intermitting for a while, often 
presenting exacerbations, but, on the whole, tending to become more and 
more pronounced. 

At first possibly the patient complains of distension, flatulence and un- 
easiness, especially after food, and of impairment of appetite ; but soon 



592 



DISEASES OF THE DIGESTIVE ORGANS. 



the uneasiness becomes pain ; and sickness presently supervenes. The 
pain varies somewhat in intensity and character. It usually begins in, 
and may remain limited to, the epigastrium, which becomes tender on 
pressure ; or it is referred to the region of the spine corresponding to the 
last two or three dorsal and first two or three lumbar vertebras, or to the 
interscapular region — the muscles on either side often being tender ; or it 
occupies the umbilicus, or some other point or area in the neighborhood ; 
and generally, when it is severe, it radiates from its point of chief inten- 
sity, upwards towards the oesophagus, backwards to the loins, or down- 
wards and laterally over the greater part of the abdominal cavity. Tiie 
pain, when severe, is of a burning, boring, or shooting character, often 
attended with a sense of soreness ; it is aggravated by taking food, and in 
some cases occurs only then. It usually comes on a few minutes after in- 
gestion, but is occasionally delayed until half an hour or an hour after- 
wards. It is doubtful how far the situation of the pain serves to indicate 
the situation of the ulcer ; but both Dr. Budd and Dr. Brinton are inclined 
to believe that pain occurring chiefly in the pit of the stomach indicates 
the presence of an ulcer in the anterior wall of the stomach, and that pain 
in the back implies a corresponding situation for the ulcer. Further, Dr. 
Brinton regards the decubitus of the patient as suggestive in this respect 
. — the patient lying as a rule on that aspect of the body which is farthest 
removed from the seat of ulceration. 

Vomiting may be absent from first to last ; it usually comes on, how- 
* ever, during the progress of the case, for the most part subsequently to the 
pain ; and is then very persistent. The attacks are determined by the 
taking of food, usually come on a little later than the pain, and not un- 
frequently by emptying the stomach cause the pain to subside. The 
vomiting may be attended with violent spasmodic efforts, or may be effected 
in the manner of simple regurgitation. Hemorrhage is a frequent conse- 
quence of gastric ulcer — taking place sometimes from the congested mucous 
membrane which bounds it, sometimes from the general surface of the 
ulcer, sometimes from a vessel which has undergone erosion. In the last 
case especially the bleeding is apt to be very profuse, and to be repeated 
from time to time ; and consequently large quantities of blood are vomited 
and subsequently passed by stool. 

The long-continuance of dyspeptic symptoms, with pain induced by 
taking food and having the characters which have been described, and 
with vomiting coming on pretty constantly at some variable period after 
ingestion, is alone strong presumptive evidence of the presence of a gastric 
ulcer. And if to these be added the occurrence of profuse haematemesis 
there can be little room for doubt. 

The most frequent termination of gastric ulcer is no doubt in convales- 
cence. There is, however, a great tendency for healed ulcers to break out 
again, and consequently for patients who seem cured to have relapses. 
When the disease ends fatally, death may be due to simple asthenia — the 
patient sinking, worn out by the combination of long-continued pain, 
vomiting, and want of food ; or it may be caused by the sudden loss of a 
large quantity of blood, or by the repetition, at longer or shorter intervals, 
of smaller but still copious hemorrhages ; or it may result from perforation. 
When perforation takes place into the peritoneal cavity, sudden intense 
abdominal pain and collapse occur, speedily followed by general peritonitis; 
and the patient usually dies in from five or six hours to two or three days 
after the occurrence of the accident. When, however, perforation takes 



ULCERATION OF THE BOWELS. 



593 



place into any of the hollow viscera or other cavities than that of the 
peritoneum, the symptoms which arise are usually much less sudden 
and grave, though still in many cases leading sooner or later to a fatal 
result. 

Treatment Attention to diet is of the utmost importance in the treat- 
ment of gastric ulcer. The patient must be nourished ; and yet all the 
digestive actions of the stomach are inimical to the cure of the lesion. We 
must consequently be especially careful as far as possible to avoid over- 
loading the stomach or causing gastric pain, uneasiness, or vomiting. With 
this object it is important to administer as little food as is compatible with 
the maintenance of life, and to give it in small quantities at a time, and at 
short intervals; it is important also to select food of such a kind as will 
impart nourishment without causing undue irritation of the stomach ; and, 
in reference to this matter, it may be observed that few articles of diet are 
so suitable as milk, which may be thickened, if necessary, with biscuit 
powder, arrowroot, or similar substances. Milk, however, sometimes dis- 
agrees, and then recourse must be had either to farinaceous substances 
mixed with water, or to animal broths and jellies. Liquids are generally 
ill borne when hot : and hence it is usually best to administer them tepid 
or cold. Hot tea and coffee especially are injurious. As the case pro- 
gresses towards recovery eggs may be given, and tender, easily digested 
meats. Alcoholic stimulants should, if possible, be avoided ; if given, they 
should be in a dilute form and cold. In some cases it is necessary to feed 
the patient for a time by means of nutrient enemata only. The chief 
medicinal agents which have been employed for the cure of ulcers are 
nitrate of silver, bismuth, the carbonated alkalies, and opium. It is certain 
that the combination of bismuth, in doses varying from ten to twenty 
grains, with opium is often very efficacious in relieving pain and vomiting 
and apparently in promoting the cure of the ulcer. Iron and the vegetable 
tonics are indicated when the more distressing symptoms have been re- 
lieved and the patient seems convalescent. When hemorrhage or any 
other serious complication occurs, special measures will be needed. 

Counter-irritation and other external treatment applied to the epigas- 
trium are often serviceable. 



V. ULCERATION OF THE BOWELS. 

Causation and morbid anatomy >] . Intestinal ulcers are much more 

common, and various in character, than those of the stomach. Their 
causes for the most part are equally obscure. In many cases, no doubt, 
simple inflammation of the mucous membrane is followed by excoriation ; 
which either rapidly heals and gets effaced, or, in consequence of con- 
tinued irritation, becomes a veritable ulcer. Such ulcers may arise from 
simple mechanical irritation. They are roundish or irregular in form, 
vary in size, and present congested and well-defined margins, and irregu- 
larly excavated shreddy grayish surfaces. The margins and the surround- 
ing tissues are in some cases considerably thickened and indurated, in 
others present little obvious departure from the normal state. Ulcers of 
this kind are not unfrequently met with in the duodenum, and in many 
cases are not improbably due to the same causes (whatever they may be) 
38 



594 



DISEASES OF THE DIGESTIVE ORGANS. 



as the so-called ' chronic ulcers' of the stomach. They are also occasionally 
met with here apparently as the result of extensive superficial burns. The 
large intestine, however, is their most common seat ; and they are pro- 
duced here for the most part by the mechanical irritation of retained feces 
or intestinal concretions. They are often found in the caecum and its 
appendage, where such accumulations are very apt to form ; but they may 
be developed at any part of the larger bowel. In cases of long retention 
of feces, whether from simple constipation or from stricture, it is not rare 
to find the mucous surface studded with tracts, varying from one to many 
square inches in area, and consisting of groups of circular ulcers from half 
an inch in diameter downwards separated from one another by a network 
of congested and partly undermined bands of mucous membrane. Again, 
such ulcers may arise in any part of the intestine, whether large or small, 
from the effects of the passage or impaction of gall-stones or other solid 
bodies, especially when impaction occurs above a stricture or other such 
impediment. 

2. In other cases ulceration is connected with the formation of a mem- 
branous pellicle ; a linear, stellate, or irregularly polygonal patch of mucous 
membrane becomes congested and swollen, and soon covered with an 
opaque whitish or buff-colored exudation, which is friable and granular, 
and extends by rootlets into the Lieberkuhnian follicles. This, after a 
time, separates, leaving sometimes a sound surface, sometimes a slight ex- 
coriation, or even a distinct ulcer, with a grayish or yellowish floor and a 
well-marked margin of congestion. These ulcers may be met with in any 
part of the bowels, but are much more common in the large than elsewhere. 
In the small intestine they affect chiefly the free edges of the valvulse con- 
niventes ; in the large, either the projecting ridges formed by the intervals 
between the sacculi, or those corresponding to the longitudinal muscular 
bands. Sometimes we find extensive tracts of congested bowel studded or 
intersected with patches or bands of membranous exudation, or consecu- 
tive ulceration, or both intermingled. This condition is met with under 
various circumstances : especially perhaps in pneumonia, and many chronic 
affections, such as Bright's disease, cirrhosis of the liver, cancer and chro- 
nic phthisis. 

3. Sometimes ulcers originate in foci of submucous suppuration, as oc- 
curs in pyaemia, or in patches of deep-seated sloughing like ordinary boils. 
Among the latter may perhaps be reckoned the ulcerative inflammation of 
the follicles of the colon, which Rokitansky describes, and is believed to 
constitute the early stage of dysentery. The follicles enlarge to the size of 
a tare or pea, become surrounded by a halo of congestion, and then under- 
going suppuration form each an ulcerated opening, which enlarges and con- 
stitutes a circular ulcer, with overlapping edges. 

4. Ulceration may be due to the formation and detachment of a superficial 
slough. Circumscribed patches of intense congestion or extravasation 
appear in the substance of the mucous membrane, which, shortly dying, 
come away bit by bit, or in mass. The above process is often effected 
with little obvious change in the immediately surrounding parts, and the 
resulting pits are for the most part speedily effaced. This affection is not 
uncommon in smallpox, typhus, and other such diseases. It frequently 
involves only the valvulse conniventes, or the corresponding projections of 
the large intestine. It may be due to sudden arterial obstruction. 

5. But sloughing, to a much more serious extent, is sometimes met 
with, espec'ally in the large intestine : patches of mucous membrane be- 



ULCERATION OF THE BOWELS. 



595 



come livid, brown, or nearly black with congestion ; and their central arese 
assume a gray or ashy color, get shrunken, depressed and softened, and 
break down into a soft, shreddy substance, which partly becomes detached, 
and partly adheres to the floors of the excavations and to their not yet 
broken-down edges. The process tends to spread. 

It is not pretended that all non-specific ulcers arise in one or other of 
the modes here enumerated, or that they necessarily maintain in their 
ulterior progress the distinctive characters of their origin. Yet, independ- 
ently of their exciting causes, and early peculiarities, all ulcers are apt 
after a time to present certain common varieties of appearance, dependent 
mainly on the processes which are actually taking place in them. Thus 
when they are healing, we find the general surface smooth and clean or 
granulating, the edges little thickened or congested, perhaps puckered, and 
probably sloping more or less obviously to the ulcerated area, with which 
they are in fact continuous ; when they are sluggish, the edges are more 
or less tumid and rounded, probably overhanging, and the general surface 
smooth ; when they are spreading, the surrounding mucous membrane pre- 
sents more or less intense congestion and swelling, and the immediate 
margin is either fiocculent and ash-colored, or presents a vivid red, raw, 
bleeding wall, or forms a more or less complete ring of distinct gangrene, and 
the floor is irregular and fiocculent. The base of an intestinal ulcer is gene- 
rally constituted by the submucous tissue, but not unfrequently the trans- 
verse muscular fibres are exposed ; and when an ulcer tends to perforate 
the bowel the muscular coat itself becomes opaque, softened, and in part 
destroyed. 

The above account applies mainly to individual ulcers. But very often, 
and much oftener in the large than in the small intestine, many ulcers are 
present at the same time, and tend to increase either in number or in size 
or in both of these respects, and to coalesce. And then, according to the 
stage to which the lesion has advanced, we meet in different cases with : 
either a number of ulcers separated from one another by an imperfect net- 
work of mucous membrane; or interlacing networks of ulceration and mu- 
cous membrane ; or islets of mucous membrane in an expanse of ulceration ; 
or, lastly, extensive tracts from which the mucous coat has been wholly 
removed. In these cases the transverse muscular fibres are often freely 
exposed, and the remains of mucous membrane are red, swollen and 
rounded, and in the form of tubercle-like excrescences. The affected 
bowel, moreover, is frequently much contracted, and the muscular walls 
hypertrophied. 

This is not the place to discuss the important subject of specific ulcera- 
tion of the bowels. Yet specific ulcers constitute by far the most formid- 
able class of intestinal ulcers. The most important of them are the 
following : — First, syphilitic ulcers ; these have not been certainly recog- 
nized in the alimentary canal excepting in the neighborhood of its inlet 
and outlet ; syphilitic ulceration of the rectum is a well-recognized, and 
for the most part very intractable, lesion. Second, the ulcers of enteric 
fever : these affect mainly Peyer's patches, and are most abundant and 
large in the lower part of the ileum ; they not unfrequently involve also 
the solitary glands of the large intestine, especially in its upper part. 
Third, tubular ulcers, which originate for the most part in the same glands 
and situations as enteric-fever ulcers. And fourth, the various kinds of 
ulcer due to the breaking down of carcinoma and other varieties of malig- 
nant disease. 



596 



DISEASES OF THE DIGESTIVE ORGANS. 



Many intestinal ulcers cicatrize and leave behind them little or no trace 
of their existence. In other cases, however, and indeed in a large propor- 
tion of them, results of more or less serious importance follow. Sometimes, 
as we see in the rectum, when a vast continuous surface has been destroyed, 
the wound never heals ; and, even in cases where the destruction has been 
much more limited, the ulcer may assume the characters so often presented 
by chronic ulcer of the stomach, and be ready, if it cicatrizes, to break out 
again and again. But generally, when a large ulcer heals wholly or in 
part, especially if it has involved the whole circumference of the bowel, 
some degree of contraction of the bowel, or stricture, results. In many 
cases hemorrhage takes place either from the congested surfaces or margins 
of ulcers, or from vessels perforated in their progress ; and such hemorrhage 
may be so frequently repeated, or so abundant, as to prove fatal. In many 
cases, also, perforation of the bowel takes place. This accident is usually 
due to a sudden tear in the floor of an ulcer, which has got unusually thin, 
and undergone softening, or become weakened in some other way ; and not 
unfrequently depends immediately on some violence inflicted from without, 
or some undue pressure from within, such as may result from over-dis- 
tension, or violent peristaltic movement. The rupture usually takes place 
at once into the peritoneal cavity, causing extravasation of fecal matter 
and generally fatal peritonitis. But not unfrequently inflammation arises 
on the peritoneal aspect of the ulcerated bowel ; adhesion takes place be- 
tween it and some neighboring viscus ; and consequently the threatened 
perforation becomes, for a time at least, averted. In many cases, a com- 
munication becomes established between the bowel and some neighboring 
hollow organ — a result preceded either by the formation of adhesions or 
by the development of a circumscribed abscess between the two organs. 
The latter mode of communication is especially liable to take place when 
the ulcer opens on the mesenteric aspect of the small intestine, or in the 
corresponding part of the larger bowel, and consequently into the connec- 
tive tissue, with which the bowel is in these situations closely invested. 
Thus, we occasionally find contiguous portions of the small intestine com- 
municating with one another, or small intestine with the transverse or some 
other part of the colon ; the rectum, sigmoid flexure or ileum with an ova- 
rian cyst, the urinary bladder, or vagina ; the duodenum or transverse 
colon with the gall-bladder ; the stomach with the transverse colon ; or, 
lastly, almost any part of the intestinal canal with the external surface. 

Symptoms and progress The symptoms of ulceration of the bowels 

are so constantly associated with those of the different morbid states of 
the system on which it depends, or those due to the various complications 
which follow upon it, that we seldom have the opportunity of studying 
them in their simple form. It maybe stated generally: that ulceration 
of the bowels is often attended with more or less obvious febrile symptoms, 
which assumes, if the disease become chronic, a distinctly hectic char- 
acter ; that the affected bowel is often more or less tender on pressure — a 
characteristic which is especially observable if the ulceration be extensive, 
or occupy the caecum or some other part of the large intestine ; that there 
is almost necessarily some impairment of nutrition marked by emaciation, 
debility, and feebleness of circulation ; that there is more or less abdomi- 
nal soreness, aching, or griping ; and that, above all, there is something 
abnormal in the action of the bowels and in the evacuations. The symp- 
toms will vary according to the seat of the disease. If the ulcer be high 
up, and especially if it be in the duodenum, the symptoms will approxi- 



ULCERATION OF THE BOWELS. 



597 



mate to those of gastric ulcer ; there will probably be pain coming on some 
time after food, and vomiting, but no material interference with the func- 
tion of defecation. If the ulceration occupy the central portion of the 
small intestine, there may be nothing beyond gradually increasing ema- 
ciation, and occasional colicky pains, to indicate that the bowels are 
affected ; and indeed extensive ulceration may be present even in the 
lower part of the ileum without occasioning any obvious modification of 
the stools ; there may, indeed, be constipation from first to last. Usually, 
however, if there be ulceration in the last-named situation, and especially 
if the large intestine be involved, more or less diarrhoea may be looked 
for. The stools are then generally liquid, and contain an abnormal quan- 
tity of the fluid secretions of the bowels, and not unfrequently more or 
less blood ; they are, moreover, often pea-soup-like in color and consist- 
ence, and more offensive than in health ; further, they are usually passed 
much more frequently than natural, and the patient suffers from frequent 
colicky pains and tenesmus. As the ulceration approaches nearer and 
nearer to the lower part of the large intestine, the evacuations assume 
more and more of the so-called ' dysenteric' character. They are then 
passed with extreme frequency and great tenesmus ; are scanty, mucous, 
often sanguinolent, and not unfrequently entirely free from true fecal mat- 
ter. The latter may be only passed occasionally in small hard lumps, in- 
vested in mucus ; indeed, constipation, so far as regards the passage of 
fecal matter, is often one of the most troublesome and distressing symp- 
toms of ulceration of the rectum and lower part of the colon. It is in the 
dysenteric form of the disease, moreover, that the evacuations become 
most offensive, the fetor sometimes being putrid and almost insufferable. 
Besides the slight oozing of blood which tinges the evacuations in dysen- 
teric diarrhoea, hemorrhage to a considerable amount sometimes takes 
place ; and this may be either continuous or recurrent, and sufficient to 
destroy life. Many of the communications which have been described as 
taking plaGe between the intestine and other organs as a result of ulcera- 
tion are doubtless of little practical importance ; but some are dangerous, 
or present features of clinical interest. Among the latter may be espe- 
cially mentioned : communications between the stomach or duodenum and 
the colon, which lead to the occasional or constant vomiting of actual feces 
and to the escape of undigested food into the large intestine ; and commu- 
cations with the urinary bladder, which occasion the escape of flatus and 
feces into that viscus, with other consequences which are easy to imagine. 
Rupture into the peritoneum generally causes fatal peritonitis. 

Treatment — Our aims in treating ulcers of the bowels should be : first, 
to promote the healing of the ulcers and prevent as far as possible the local 
mischances which are apt to follow ; second, to check abdominal discom- 
fort and diarrhoea; and, third, to support the patient's strength. It is of 
course doubtful how far remedies given by the mouth can act locally on 
ulcers low down in the bowels, and how far, therefore, substances like 
bismuth, nitrate of silver, iron, copper, mineral acids, and the like can 
promote cicatrization ; still they are often employed with this object, and 
sometimes apparently with benefit. But it is of great importance that the 
bowels should be kept at rest, and violent peristaltic movement as far as 
possible restrained. Purgatives, therefore, should be in great measure, or 
wholly eschewed; while astringent medicines — iron, copper, lime, chalk, 
tannic acid, or vegetable astringents — will probably prove serviceable. 



598 



DISEASES OF THE DIGESTIVE ORGANS. 



Opium is especially valuable ; and the compound kino powder, and the 
combination of aromatic chalk powder with opium, are useful preparations. 
It is important, however, to note that opium cannot always be taken in 
these cases ; for chronic ulceration of the bowels is often attended with an 
irritable state of the mucous membrane of the mouth and stomach which 
the use of opium is apt to augment. If this drug cannot be employed, it 
may be replaced to some extent by other sedatives, such as hyoscyamus, 
belladonna, Indian hemp, or hydrocyanic acid. Opium may often be given 
with advantage in the form of enema or suppository. It is obvious that 
the various measures which have just been enumerated, while they check 
peristalsis, act with equal efficacy in fulfilling the second indication of 
treatment — namely, the arrest of diarrhoea. The maintenance of the 
patient's strength must be effected by the use of tonic medicines and the 
careful administration of suitable food and stimulants. The form of tonic 
must be adapted to the special requirements of the case, and to the other 
details of treatment it may be considered necessary to adopt. As regards 
food, this should be well-cooked, well-masticated, easy of digestion, given 
in moderate quantities, and at regular if not frequent intervals. Farina- 
ceous foods are in many cases most suitable; but eggs, fish, and fowl may 
often be used with advantage. Butcher's meat is sometimes wholly in- 
admissible. 

[Duodenal Ulcers — Recent investigations seem to show that ulcers of 
the duodenum are of much more frequent occurrence and importance than 
had been previously thought. Thus, according to Niemeyer, duodenal 
ulcers or their cicatrices were found by Willigk seventy-six times in one 
thousand post-mortem examinations; in two cases the ulcers being perfor- 
ating. They are usually situated in the upper horizontal portion. The 
disease affects men oftener than women, is most common after middle age, 
and is rare in childhood. The ulcer resembles the gastric ulcer closely in 
appearance, and is believed to depend upon the same cause — thrombosis of 
a small vessel and subsequent necrosis of the mucous membrane supplied 
by it. Sometimes the ulcer in cicatrizing causes stricture of the duodenum, 
at other times obliteration of the ductus choledochus. 

The symptoms of duodenal ulcers are generally very obscure, differing 
little, if at all, from those caused by gastric ulcers. In most cases their 
existence is unsuspected during the lifetime of the patient; in other cases 
attention is only awakened to the possibility of their presence by the occur- 
rence of vomiting of blood, followed by suppression of the urine and col- 
lapse, and, if he survives long enough, by peritonitis. They have occasion- 
ally, however, given rise to dyspeptic symptoms and to pain, referred by 
the sufferer to the region occupied by the duodenum, and coming on some 
hours after meals. Vomiting is less frequent than in gastric ulcers, but it 
is sometimes observed. Icterus too may be present, but not so often as we 
should expect from the duodenum being the seat of the disease. 

The treatment to be pursued is essentially the same as that recommended 
for gastric ulcers. Niemeyer speaks favorably of the use of alkaline and 
alkaline-saline mineral waters. The diet should be carefully regulated.] 



I 



TYPHLITIS. 



599 



VI. PERFORATING ULCERS OF THE CECUM AND 
RECTUM. 

( Typhlitis, Perityphlitis, and Periproctitis.) 

There are certain parts of the bowels which are especially liable to be- 
j come the seat of non-specific forms of inflammation and ulceration, or to 
i be involved in inflammation originating in their neighborhood; these are 
j the duodenum and the large intestine — more particularly the caecum and 
! lower part of the rectum. 

As to the duodenum, we have already pointed out that it is not unfre- 
! quently the seat of ulcers which resemble chronic ulcers of the stomach, 
and of ulcers arising in connection with extensive burns of the skin. We 
I may add that from its situation and attachments it is liable to become per- 
| forated from without by abscesses of the gall-bladder and liver, and by 
abscesses originating, no matter how, in the upper part of the retro-peri- 
toneal tissue. 

So, also, the large intestine, from its peculiar relations with the peri- 
toneum, and from the extent to which it is in many places devoid of 
peritoneal covering, and continuous, therefore, with the sub-peritoneal 
connective tissue, and thus brought into almost immediate connection with 
the various organs lying beneath the parietal peritoneum, is particularly 
apt to be involved in extraneous inflammation and suppuration. For 
similar reasons (at least in great measure) inflammation originating here 
is very liable to induce inflammatory thickening and abscess in the sur- 
rounding tissues. 

A. Typhlitis. Perityphlitis. 

Causation and morbid anatomy The terms 'typhlitis' and 'perityphli- 
tis' (the former signifying inflammation of the walls of the caecum, the 
latter inflammation of the tissues surrounding it) are commonly employed 
in reference to those cases in which inflammation of the caecum or its 
vermiform appendage involves, either by perforation or by simple exten- 
sion, the connective tissue of the iliac fossa or the peritoneal cavity. 
Ulceration of these parts very frequently takes place (in enteric fever and 
phthisis to wit) without causing the special phenomena of typhlitis. There 
is reason, indeed, to believe that in most, if not all, cases where inflamma- 
tion spreads from the caecum to the surrounding tissues, its spread is re- 
ferable to ulcerative perforation. The causes of the lesion in question are 
no doubt various. It may be due to the extension of tubercular, typhoid, 
or dysenteric ulcers, to simple but extreme distension of the caecum, to 
the fretting of its surface by accumulated fecal contents, to the mechanical 
effects of bristles, pins, or bits of bone which have been accidentally swal- 
lowed, or to the lodgment of intestinal concretions. Concretions are mostly 
found in the vermiform appendage and are the usual causes of perforative 
ulceration of this part. They vary from the size of a pea to that of a 
date-stone, are sometimes of a waxy consistence and lustre, sometimes 
brown, opaque, laminated, and for the most part fecal, sometimes com- 
posed mainly of earthy phosphates, but consist in all cases of an admixture 
in unequal proportions of ordinary fecal matters and the secretions from 
the mucous surface, and are occasionally developed around small extrane- 
ous bodies. 



600 



DISEASES OF THE DIGESTIVE ORGANS. 



In some cases the ulcer perforates that portion of the bowel which is 
devoid of peritoneal covering. Fecal matter then escapes into the sur- 
rounding tissues, leading to more or less extensive inflammation and indu- 
ration. If the escape be slight inflammatory swelling alone may take 
place, and after a while subside. Often, however, an abscess forms, which 
enlarges more or less rapidly, and then extends in a direction determined 
in great measure by its original seat: in one case descending into the 
pelvis and opening into the rectum ; in another passing out with the pyri- 
formis muscle and presenting in or below the buttock; in another forming 
a swelling in the groin immediately above Poupart's ligament, or passing 
along the inguinal canal into the scrotum, or along the psoas and iliacus 
muscles into the upper part of the thigh. In most cases no doubt it pre- 
sents itself in the iliac region superficial to the position which the caecum 
normally occupies. An abscess of this kind may get cured by discharging 
its contents either through the orifice in the caecum whicji gave rise to it 
or through an opening at any one of the spots which have been enumerated ; 
or, burrowing extensively, it may form a sinus or series of sinuses which 
are never obliterated. The communication between the abscess and caecum 
is sometimes maintained ; at other times it closes more or less speedily, 
and the abscess appears henceforth to be independent of the bowel. In 
some cases (especially if the part affected be the vermiform process), local 
peritonitis precedes or accompanies the perforation, which would otherwise 
have been direct into the general peritoneal cavity; and a circumscribed 
abscess forms, the indications and progress of which differ little, if at all, 
from those of the abscesses previously considered. In other cases rupture 
takes place directly into the peritoneal cavity and fatal peritonitis is ex- 
cited. It may be added that the circumscribed abscesses themselves may 
rupture ultimately into the peritoneum. 

The most common form of fatal typhlitis is that connected with perfo- 
ration of the vermiform appendix — an accident which occurs mainly in 
early life, and apparently often er in males than in females. 

Symptoms and progress The sj^mptoms of typhlitis are, in the first 

instance, pain, tenderness, and swelling in the region of the caecum, to- 
gether with signs of inflammatory fever, and sometimes rigors. The local 
symptoms are for the most part those which may be caused by inflamma- 
tion of whatever origin occupying the venter of the ileum. If an abscess 
forms, but extends downwards into the pelvis, or remains deep-seated, the 
case is naturally obscure. If, however, it tends to point anteriorly, the 
fulness and hardness get more and more pronounced, and gradually develop 
into a fluctuating hemispherical protuberance over which the integuments 
become oedematous and congested. Sometimes, even at this stage, the 
swelling gradually subsides and disappears, owing to the abscess having 
discharged itself into the bowel ; but more frequently it still enlarges and 
ultimately opens externally, discharging a greater or less amount of fetid 
pus, sometimes having a fecal odor, sometimes containing fecal matter and 
bubbles of gas. The further progress of the case may be towards either 
more or less speedy recovery, or the formation of successive abscesses or 
fistulae, or the establishment of an artificial anus. When peritonitis arises 
from perfection of the caecum or its appendix, its occurrence may be quite 
sudden and unpreceded by any form of premonitory symptoms ; but occa- 
sionally it is heralded by localized uneasiness or pain, or (as we have 
pointed out) supervenes in the course of well-marked perityphlitis. 

The functions of the alimentary canal are by no means necessarily dis- 



PERIPROCTITIS. 



601 



turbed to any great extent in typhlitis. Sickness is often absent. Con- 
stipation is not unfrequently present during the earlier period of the disease ; 
while diarrhoea is apt to supervene at a later stage. But none of these 
symptoms has any particular uniformity or value. It may be remarked 
that, from the close proximity of the caecum to important veins and nerves, 
typhlitis is apt to induce painful neuralgic symptoms and oedema of the 
right lower extremity. Its duration is necessarily very uncertain. Some- 
times the patient speedily recovers, sometimes he lingers indefinitely with 
a constantly discharging abscess or a succession of abscesses. If, however, 
perforation take place into the peritoneum death rapidly follows. 

Although inflammation beginning in the caecum is a very common and 
important cause of inflammatory swelling and suppuration in the right 
iliac fossa ; it must not be forgotten that this part is also a common seat 
of inflammation and abscess from other causes, and further, that such ab- 
scesses are liable to form communications with the caecum, and hence still 
further to simulate primary typhlitis. Among the affections here referred 
to may be enumerated : inflammation of the ovary and connective tissue in 
its neighborhood ; idiopathic abscesses of the venter ilii, or in the course 
of the psoas muscle ; psoas abscess from caries of the spine ; renal abscess ; 
and all descending retro-peritoneal abscesses, whether from the interior of 
the spinal canal, the pleura, lung, or liver. 

Treatment The treatment of typhlitis is in principle, and indeed in 

most of its details, the same as that of enteritis and other forms of intestinal 
ulceration. It consists mainly in keeping the bowels quiet by the aid of* 
opium, and in the use of local applications. It is almost more important 
in typhlitis than in any other affection to avoid opening medicines; for, 
especially if the disease be in the appendix, rupture into the peritoneum is 
in many cases prevented solely by slight adhesions. This danger often 
continues, indeed, for sometime after the local inflammation seems to have 
subsided ; and caution, therefore, should be exercised in respect of the use 
of purgatives for some time after apparent restoration to health. If the 
bowels need to be relieved simple enemata are the safest agents, and are 
usually sufficient. The local measures to be employed comprise leeches, 
fomentations, and the application of ice ; and if an abscess form, its speedy 
evacuation. Those who have once suffered from typhlitis are liable to 
recurrences of the disease, and require to take great care in respect of diet, 
exposure to cold, and other conditions likely to act injuriously. 

B. Periproctitis. 

Causation and morbid anatomy Inflammation and suppuration about 

the lower part of the rectum are even more common than the correspond- 
ing affections of the caecum ; and their causes are equally various. In 
many cases this affection is traceable to ulceration (perforative or other) 
of the mucous membrane; in others it probably originates in the connective 
tissue which surrounds the rectum. Further, the rectum (again even more 
frequently than the caecum) gets involved in inflammation and suppuration 
originating in the various pelvic and even distant organs. Abscesses, in 
fact, arising in the abdominal cavity or its walls, or implicating them, are 
peculiarly apt to gravitate into the pelvis, and to communicate with the 
rectum. Rectal abscess is frequently connected with the presence of tuber- 
culosis. 



602 



DISEASES OF THE DIGESTIVE ORGANS. 



Symptoms and progress — Inflammation in the neighborhood of the 
lower part of the rectum necessarily produces tumefaction and induration, 
which may usually be readily detected by digital examination per anum, 
or by their presence in the perineum in the immediate vicinity of the 
anus. In connection with the swelling there are always more or less 
severe pain and tenderness, which often prevent the patient from sitting 
down, and are greatly aggravated during the act of defecation. If sup- 
puration take place, the swelling rapidly increases in size, and the abscess 
presently opens either into the rectum (usually a little within the internal 
sphincter), or externally by the side of the anus, or in both of these situa- 
tions, and discharges exceedingly fetid pus. Simple inflammation around 
the rectum may subside spontaneously ; but an abscess almost invariably 
results in the formation of a fistula which is a peculiarly obstinate affec- 
tion, and rarely yields excepting to direct surgical treatment. When an 
abscess opening into the rectum is connected directly with suppuration of 
some remote organ, the ultimate prospects of recovery are by no means 
satisfactory. 

The treatment consists in the application of fomentations, poultices, or 
leeches, and the opening of the abscess as soon as the presence of pus is 
ascertained. The bowels, moreover, should be regulated either by laxa- 
tives or by enemata. 



VII. DYSENTERY. 

Definition TVe have already, in describing inflammation and ulcera- 
tion of the bowels, discussed the various inflammatory processes which 
take place in the large intestine, and considered the symptoms to which 
they give rise. These affections, especially if they involve its lower segment, 
always induce so-called ' dysenteric' symptoms, and are usually included 
in the generic term 'dysentery.' But dysentery is also the name of one of 
the most widespread and fatal of diseases — a disease which, under special 
circumstances, assumes an endemic or even epidemic character, and is 
hence not unnaturally regarded as a specific disease, in the same sense as 
ague and enteric fever are specific diseases. 

Causation — Dysentery prevails largely in tropical regions, and more 
especially in those places which are low and swampy, and surcharged with 
decaying vegetable matter — in regions indeed which are, for the most part, 
malarious and breed intermittent fevers. It occurs, however, under con- 
ditions and in places which are not productive of ague ; it has been in all 
ages one of the greatest scourges of armies in the field, in beleaguered 
cities, and of starving populations. According to Sydenham and others 
of our older writers, it was once a formidable disease in this country ; 
whence in an aggravated and epidemic form it has now almost entirely 
disappeared. It is probable, however, that enteric fever formed a large 
proportion of the cases then termed dysenteric. From its frequent coin- 
cidence in area of distribution with ague it is by many regarded as being, 
equally with that disease, a product of the malarial poison. But the facts 
that aguish districts are not necessarily also dysenteric ; that dysentery, 
even in an epidemic form, occurs in places and under circumstances which 
never yield ague ; and that ague and dysentery no more graduate into one 



DYSENTERY. 



603 



another than do enteric and typhus fevers, render this view of its origin 
untenable. The influences of foul water, polluted air, insufficient nourish- 
ment, and exposure and over-fatigue in its production are unquestionable, 
but whether as exciting causes or merely as prediposing causes is by no 
means clearly established. There is reason, however, to believe that pol- 
luted drinking water is an especially active agent in the induction of the 
disease, but whether by the introduction, of a specific poison is, at least 
doubtful. We are inclined to regard dysentery as botH of non-specific 
origin and non-infectious ; and, on these grounds, introduce its description 
here. 

Morbid anatomy — The morbid anatomy of dysentery has been abun- 
dantly described, but the descriptions which have been given of it are 
various, and do not admit of being readily reconciled. Some of the most 
trustworthy of recent observers, such as Parkes and Baly, regard it as a 
disease essentially of the solitary glands of the large intestine, which rise 
up in the form of hemispherical buttons, varying from the size of a millet- 
seed downwards, and occasionally attaining the bulk of a split pea. Asso- 
ciated, however, with glandular hypertrophy there is always more or less 
intense congestion of the general surface of the mucous membrane, which 
becomes sepia-colored, reddish-brown, or almost black ; together with 
inflammatory infiltration of its substance and of the submucous tissue, 
which may consequently acquire a collective thickness of one-quarter or 
even one-third of an inch. 

It must, we think, be admitted that dysentery commences with conges- 
tion, more or less intense, and infiltration, more or less conspicuous, of the 
mucous membrane, in which changes the solitary glands not improbably 
take a predominant share. This inflammation (at all events in the first 
instance) usually occurs in scattered patches, which are linear, stellate, or 
irregularly roundish or polygonal, are peculiarly liable to involve the pro- 
minent folds, and are sometimes limited to them. The patches may be 
discrete, or they may run together, forming an irregular network, or they 
may coalesce completely over a more or less extensive area, and even 
throughout the whole length of the large intestine. It usually happens 
that, in addition to the interstitial inflammatory changes here adverted to, 
the affected surface becomes early covered with a thin, opaque, granular 
film, or with such films in patches. These can usually be readily removed 
from the subjacent surface, bringing with them adherent casts of the Lie- 
berkiihnian follicles. They consist, in fact, mainly of an inflammatory 
overgrowth of the intestinal follicular epithelium. 

If the dysenteric attack be slight, the morbid process may cease at this 
point, and convalescence become established without any material injury to 
the bowel. But if it be severe, further changes speedily ensue. These 
present considerable variety, but consist essentially in the formation of 
sloughs and (by the separation of these) of ulcers. The sloughs vary in 
color, size, shape, and arrangement. They may be yellow, like those of 
enteric fever, or ash-colored, or black. They are sometimes circular and 
distinct, studding the surface more or less uniformly and thickly; some- 
times they occur in irregular groups, and constitute patches of various, 
and often considerable, extent ; sometimes they so run together and are 
so arranged as to constitute a network the interstices of which are formed 
by isolated patches of mucous membrane ; sometimes extensive tracts of 
surface are uniformly and completely destroyed ; and in all cases there is 
more or less tendency for the morbid process to spread, either by simple 



604 



DISEASES OF THE DIGESTIVE ORGANS. 



ulceration, or by the burrowing of pus beneath the mucous surface, or by 
sloughing. With the separation of the sloughs ulcers are left, sometimes 
with ragged, sometimes with abrupt, and often with swollen and congested 
margins, and with floors formed either by the submucous tissue or by the 
transverse muscular fibres. 

The subsequent progress of the morbid process varies. In some cases 
more or less perfect cicatrization ensues ; in some, the ulcers assume a 
chronic character, and remain open, and with little alteration, for art indefi- 
nite period ; and in either of these cases there is a tendency to the recurrence 
of active inflammation under slight provocation. When the disease lapses 
into the chronic form, the affected bowel is apt to remain exceedingly irri- 
table, to become permanently contracted, and as regards its muscular coat 
sometimes greatly hypertrophied. It must be added : that perforation of 
the bowel is an occasional complication of dysentery ; that inflammation 
sometimes pervades the whole thickness of the intestinal walls, extending 
even to the peritoneal aspect ; that more or less hemorrhage from the in- 
flamed or ulcerated surface is almost invariable, while in some cases it is 
so abundant as to cause death ; and that the cicatrization of dysenteric 
ulcers not unfrequently causes stricture. 

Dysenteric inflammation may occupy any part of the large intestine, or 
the whole of it, and may be prolonged for a considerable distance up the 
ileum. It is most common, however, in the lower part of the colon and 
in the rectum, and is usually most severe and most advanced in these 
situations. 

Other lesions besides those of the bowels are often met with in dysen- 
tery. The most common are engorgement of the lymphatic glands in re- 
lation with the inflamed mucous membrane, and congestion of internal 
organs, more especially of the liver, spleen, kidneys, and lungs. In asso- 
ciation with the dysentery of tropical climates abscess of the liver is not 
uncommon. This complication is referred by Dr. Geo. Budd to portal 
pyaemia, taking its rise from the diseased mucous membrane of the bowel. 
Hepatic abscess, however, sometimes originates simultaneously with the 
dysentery, sometimes precedes it ; and hence it seems more probable that 
the two lesions are concurrent effects of the same cause, and not depend- 
ent the one on the other. 

Symptoms and progress. — The symptoms of dysentery comprise those 
of pyrexia and those due directly to the morbid processses going on in the 
large intestine — the latter being mainly determined by the excessive irri- 
tability and tendency to spasmodic contraction of the larger bowel, and 
by the fact of the constant discharge into it of the morbid products of the 
diseased mucous surface. 

In the milder forms of the disease the patient, after suffering, perhaps, 
for a short time from more or less heat and dryness of skin, clamminess 
of mouth, and vague griping pains, is attacked almost suddenly with an 
uncontrollable impulse to evacuate his bowels, and probably passes a solid 
motion with unusual ease — the mass being invested in a greater or less 
abundance of grayish or colorless mucus. The usual sense of relief, how- 
ever, does not follow, and he probably finds himself compelled to sit 
straining at stool, with fits of spasmodic violence, during which he dis- 
charges small quantities of offensive mucus, and probably a minute fecal 
lump or two. With the continuance of the affection the febrile disturb- 
ance continues ; the tongue probably becomes coated ; a constant sense of 
uneasiness, heat, or burning pervades the anus and adjoining parts of the 



DYSENTERY. 



605 



1 rectum, and more or less, perhaps, of the large intestine. The patient 
suffers from frequent tormina, and impulse to evacuate the bowels — the 
efforts being attended with much tenesmus, and the discharge mainly of 

! small quantities of mucus. This may be stained with fecal matter, and is 
often intimately mixed with blood, and may consequently present very much 

I the appearance of pneumonic expectoration. But, notwithstanding the 
almost constant efforts at defecation, there is, so far as actual fecal matter 
is concerned, almost complete constipation. A few scybala only are passed 
from time to time. Cases of this kind may subside in the course of a day 
or two, and seldom last longer than a week or ten days. Nevertheless 
some irritability of the bowels, uneasiness after defecation, and tendency 
to constipation, may trouble the patient for a considerable time after he 
seems to have regained in other respects his ordinary good health. 

In the more severe forms of dysentery the symptoms are similar in 
kind, but much more intense. The disease is usually ushered in with 
high fever, often with alternate chills and flushes of heat, sometimes with 
distinct rigors, and occasionally even with convulsions. The skin is hot, 
the pulse accelerated; there are febrile pains and headache, anorexia, 
thirst, and dryness and furring of the tongue. In this, as in the former 
case, the intestinal affection is usually first indicated by the occurrence of 
griping pains, which are presently followed by the evacuation of the con- 
tents, often solid, of the lower bowel. But very soon the griping becomes 
frequent and severe, calls to stool are incessant, and the patient suffers 
from almost constant tenesmus. The matters discharged from the bowels 
are at first a whitish, brownish, or olive-colored glairy or jelly-like mucus ; 
but this soon gets sanguinolent, and not unfrequently intermingled with 
considerable quantities of dark and more or less clotted blood. After a 
while the discharges commonly assume those characters which give them a 
resemblance to ' meat-washings ;' they become thin, watery, turbid, reddish, 
and dirty-looking, and contain brownish or blackish particles, which are 
fragments either of altered blood-clots or of sloughy mucous membrane. 
It is at this time also that the patient frequently passes soft membranous 
pellicles, which are either tracts of mucous membrane detached in bulk, 
or portions of false membrane. Dysenteric evacuations are further char- 
acterized : by a peculiar and almost insupportable fetor, which increases 
in intensity with the supervention of sloughing ; by containing a large 
quantity of dissolved albumen ; and by the occasional presence of small 
solid fecal lumps or scybala. They sometimes become purulent. The 
frequency w T ith which the bowels act is often very remarkable. In some 
cases the patient seems for a length of time never to cease discharging 
small quantities of fluid. The bowels are often relieved four or five times 
in the hour, and sometimes as many as ten or twenty times in the same 
period. The quantity of fluid passed, however, is not necessarily in rela- 
tion with the frequency with which the bowels act. In many cases, espe- 
cially at the beginning, the discharge is scanty ; but later on considerable 
quantities of serous fluid, or blood, or both, are apt to escape, and the 

j total bulk of these discharges in the twenty-four hours is hence often very 
large. 

Associated with tenesmus and alvine flux are burning pain within the 
anal orifice, and a constant sense of the lodgment there of something 
which needs to be got rid of ; there is also more or less burning pain and 
tenderness on pressure in the course of the large intestine and especially 
of those parts which are chiefly involved. At first probably the abdominal 



606 



DISEASES OF THE DIGESTIVE ORGANS. 



parietes are rigid and retracted ; but before long flatus accumulates and the 
abdomen consequently gets enlarged and tympanitic ; the tongue becomes 
thickly coated ; the patient complains of thirst, loathes food, and not un- 
frequently suffers from nausea and vomiting ; the urine is scanty and high- 
colored, and its discharge sometimes attended with pain or difficulty ; the 
febrile excitement which ushered in the disease rapidly gets replaced by a 
condition of profound depression ; the skin may yet be hot and dry, but 
the pulse becomes small, feeble, and rapid, the face anxious, and the patient 
restless, sleepless, and desponding. 

Cases which end favorably usually manifest signs of amendment from 
the sixth to the tenth day ; these consist in abatement of fever and other 
general symptoms, and gradual cessation of tenesmus and the peculiar 
dysenteric stools. But convalescence is usually much protracted ; and 
some time elapses before the bowels completely regain their normal tone. 
In those cases which end fatally the pulse increases in rapidity, loses ful- 
ness and power, and often becomes scarcely perceptible ; the surface tends 
to grow cool; the face and extremities acquire a shrunken and dusky 
aspect ; the tongue becomes dry and brown or black ; hiccough and vomit- 
ing come on ; and the abdomen grows more and more tympanitic. Al- 
though probably continuing restless and desponding, the patient often 
retains his senses perfect to the last ; sometimes, however, he becomes 
delirious (in some cases, indeed, delirium comes on early), and he may 
then pass into a state of stupor or coma. It very commonly happens that, 
with the increase of tympanites, the abdominal pain, colic, and tenesmus 
all subside and even disappear wholly. The symptoms which precede 
death, and the mode of death, are necessarily modified to some extent by 
the special circumstances of the case ; they are, for example, somewhat 
different in such cases as are attended with profuse hemorrhage from what 
they are in those in which intestinal perforation takes place, or which are 
complicated by hepatic abscess, or where the patient sinks under the in- 
fluence of the uncomplicated disease. Under all circumstances, however, 
the immediate cause of death is asthenia. 

Many cases of acute dysentery, instead of taking either of the two 
courses which have been considered, become chronic ; and the disease 
continues, with occasional remissions and exacerbations, for an indefinite 
period. The patient is then an almost constant sufferer from colic and 
tenesmus, and the discharge of offensive liquid stools containing little true 
fecal matter, and from retention, often to a very uncomfortable extent, of 
his solid feces; he complains of abdominal tenderness and uneasiness ; his 
tongue is in some cases dry, glazed, and fissured, in others coated, in others 
almost normal ; and his appetite presents equal variations ; more or less 
sickness is often present; and he becomes emaciated, weak, anaemic, ana- 
sarcous, and often hectic. If an hepatic abscess be present, the symptoms, 
or many of them, are aggravated, and probably the indications of hepatic 
tumor are presently superadded. Chronic dysentery varies greatly in its 
severity, and in some cases, even though lasting for years or throughout 
life, is, excepting from the discomfort which attends it, of comparatively 
little importance. 

As a rule, sporadic dysentery is not a very fatal disorder; but the epi- 
demic form is usually attended with a high mortality; and although, even 
here, the ratio of deaths to attacks is sometimes small, the cases are so 
numerous and the total mortality usually so high, that it is-justly regarded 
as one of the most fatal of epidemic diseases. 



DYSENTERY 



607 



Treatment — There is little unanimity of opinion with regard to the 
treatment of dysentery ; some authors strongly advocate the copious ab- 
straction of blood, if not by venesection, at any rate by leeches ; some 
j place their chief reliance on calomel in large doses ; some regard ipecac- 
uanha as almost a specific ; some pin their faith to purgatives, some to 
| opiates ; while, on the other hand, each of these remedies has been more 
or less strongly condemned. Of the immediate relief which follows the 
! abstraction of blood there is probably little doubt ; but it is obvious that 
■ the marked tendency to asthenia which exists in dysentery supplies a pow- 
erful argument against the indiscriminate and excessive use of blood-letting. 
! As a rule, it is doubtless unnecessary; but if employed it should be em- 
I ployed early, and preferably effected by the application of leeches to the 
tender regions of the abdomen. Calomel has been administered (as it was 
formerly in cholera) in large doses with reputed success ; it has, however, 
fallen into disuse, and probably deservedly. Ipecacuanha has enjoyed a 
long but various reputation. It was formerly regarded as an almost un- 
failing specific, and at the present day is very highly esteemed. There 
j are at least two antagonistic principles on which it is administered. By 
| Trousseau and other French authorities it is given in doses of ten or twelve 
grains of the powder every ten minutes or so, until copious vomiting re- 
sults — the essence of the treatment being, according to them, the production 
of a powerful evacuating effect upon the stomach ; by English army surgeons, 
on the other hand, it is recommended to be given in a large dose (twenty- 
five to thirty grains), which is to be repeated at the end of eight or ten 
hours ; but it is to be given, guarded by opium, and with every precaution 
against sickness, in order, that the remedy may act directly, or indirectly 
through the system, on the affected mucous surface. Bretonneau advo- 
cated the use of saline purgatives in large doses, and in this advocacy he 
is strongly supported by Trousseau. Opium and astringents are often em- 
ployed ; but the former (except in infinitesimal doses) is strongly con- 
demned by the last author. 

It may, we think, be fairly asked whether there are any good grounds 
for believing that dysentery is more amenable to treatment, specific or non- 
specific, than other forms of enteritis are ; and whether there is sufficient 
reason for adopting a radically different treatment from that which has 
been found generally useful in enteritis ? In acute and severe cases we 
should be disposed in the first instance : to apply hot fomentations to the 
belly, and if there be much local pain and distress, to abstract blood by 
means of ten, twenty, or thirty leeches ; to exhibit opium, or opium with 
ipecacuanha, in doses sufficiently large or sufficiently frequently repeated 
to relieve the tormina, tenesmus, and abdominal pain ; and to use enemata 
either simply to wash out and cleanse the lower bowel, or to soothe it, or 
for the purpose of applying astringent or other medicaments directly to its 
surface. We should prefer, in the early stage of the disease, small ene- 
mata of gruel containing laudanum, or opium, or morphia suppositories, 
j The patient's diet should consist of milk, gruel, broths, eggs, and such-like 
I articles, together with such a proportion of alcoholic stimulants as the case 
| may seem to need. If sickness be present, it must be treated with ice and 
I such remedies as are generally useful in relieving sickness. When the 
dysentery passes into the chronic state, the use of astringent medicines 
and of vegetable tonics is indicated. The former may comprise copper, 
| lead, iron, and tannin, together with other vegetable astringents, the latter 
a wide range of vegetable infusions. At this period also enemata are 



I 



608 DISEASES OE THE DIGESTIVE ORGANS. 

likely to be particularly serviceable ; of which those containing copper, 
lead, tannin, sulphate of zinc, or nitrate of silver have been strongly rec- 
ommended in the belief that they have a direct beneficial action on the 
diseased mucous membrane. We believe it to be a good plan to wash out 
the bowel night and morning with as large an injection of warm water or 
gruel as can be introduced without pain, and then to insert a morphia 
suppository. In treating dysentery it must not be forgotten that in both 
acute and chronic cases fecal matter tends to accumulate above the diseased 
portion of bowel, and that this needs from time to time to be removed. 
For this purpose it may be necessary to administer an occasional purga- 
tive. In mild cases of the disease it is often well to commence the treat- 
ment with a dose of castor oil, and to continue it with mild astringents, 
such as compound kino powder, Dover's powder, or aromatic chalk and 
opium. 



VIII. PERITONITIS. 

Causation. — Peritoneal inflammation is of common occurrence in both 
sexes and at all periods of life. It is due to various causes. In some 
cases it is idiopathic, or the result of exposure to cold and wet, or gene- 
rally to those exterior conditions to which inflammations of other organs 
are so commonly traceable. Idiopathic peritonitis may attack the robust 
and healthy ; it is more common, however, in those who are anasmic, 
debilitated, or broken down in constitution, and in those who suffer from 
obstructive diseases of the heart, lungs, or liver, and especially in such as 
are laboring under chronic Bright's disease. In many cases peritonitis is 
due to the simple extension of inflammation from neighboring parts. It is 
thus developed, in the course of enteritis or gastritis, in connection with 
inflammatory affections of the liver, spleen, kidneys, or bladder, and in 
dependence on pleuritis, pericarditis, or inflammation of the abdominal 
parietes. The most fruitful causes, however, of grave peritoneal inflam- 
mation by simple extension are inflammation of the ovaries, uterus, and j 
other pelvic organs in females, and especially that form of uterine inflam- 
mation which follows upon parturition. In many cases, again, peritonitis 
is caused by mechanical injury — sometimes by external wounds ; more j 
frequently by the perforation or rupture of some viscus and the extravasa- \ 
tion of its contents or of foreign matters into the peritoneal cavity. Among 
such cases must be enumerated: ulcerative perforation of the stomach and 
duodenum ; perforation of the small intestine (usually the ileum) by 
tubercular, typhoid, or other ulcers; perforation of the caecum, vermiform 
appendix, colon, or rectum, consecutive to tubercular or typhoid ulcers, 
dysentery, or mere over-distension ; rupture of an hepatic abscess, of the 
gall-bladder or common bile-duct, of an hydatid cyst, or of a psoas, renal, . 
or other abscess; rupture of the uterus, or ovarian cysts; and, besides 
these, the laceration, from external violence, of the liver, spleen, kidneys, | 
intestine, or bladder. Further, peritonitis is a frequent concomitant of 
abdominal tubercle or carcinoma, and a not uncommon result of pyemic or 
metastasic processes. 

Morbid anatomy The morbid changes which take place in the inflamed 

peritoneum are precisely similar to those attending inflammation of other 
serous membranes. They consist in dilatation of the minute vessels, with J 



PERITONITIS. 



609 



accumulation of blood within them and infiltration and thickening of the 
subserous tissue; and in inflammatory hyperplasia of the epithelial invest- 
ment, with effusion from ,the subjacent vessels of modified plasma of the 
blood, of which part coagulates on the surface, forming, with entangled 
corpuscles, a false membrane, and part (mainly fluid) accumulates in the 
cavity. The first visible indications of peritoneal inflammation consist in 
most cases : in more or less intense capillary congestion, which is usually 
observed to extend in bands (determined by the pressure of the organs 
against one another) along the intestines ; and in more or less loss of 
polish, due to the commencement of inflammatory exudation. With the 
advance of the disease, the congestion becomes more intense, and patchy, 
and sometimes complicated with subserous extravasations ; and the solid 
inflammatory exudation increases in quantity. This forms in the first 
instance a thin, grayish, granular lamina; but as it increases in thickness 
acquires a more distinctly yellow tinge, and becomes, according to its 
quantity and position, ribbed, villous, papular, or honeycombed. The false 
membrane varies in thickness from a delicate film to a quarter or half an 
inch, or more ; and in quality from a mere pulp to a coherent elastic 
lamina. It usually acquires toughness with age ; and the deeper-seated 
portions are always tougher than the more superficial. It tends to accu- 
mulate in the dependent parts of the peritoneal cavity, and to cause more 
or less intimate adhesion between neighboring organs. The fluid effused 
in the course of peritonitis is often small in quantity, and, subsiding into 
the pelvis and lumbar regions, apt to escape detection ; on the other hand, 
it is sometimes very copious, and causes much abdominal distension. It 
is chiefly abundant in chronic cases. It is usually opalescent, containing 
exudation corpuscles, and fibrinogen, which readily coagulates. The spaces 
occupied by the fluid are commonly traversed by filaments, bands, or 
bridles, of coagulated lymph. 

Peritonitis, even when of local origin, generally soon involves the whole 
of the peritoneal surface. In some cases, however, it remains localized. 
Thus it may be confined to the neighborhood of the liver, spleen, caecum, 
or pelvic organs. The great omentum not unfrequently effectually limits 
its spread. Convalescence from simple peritonitis is attended with absorp- 
tion of the dropsical effusion, subsidence of the inflammatory congestion, 
and organization of the false membrane, with its gradual conversion into 
connective tissue. The usual consequences are that the peritoneal surface 
gets thick and opaque, and the viscera united to neighboring parts and 
compressed by the contracting adventitious membrane. Thus the liver 
and spleen become adherent to the diaphragm ; and the small intestines 
grow together, and are not unfrequently welded into an apparently homo- 
geneous lump. Further, the liver and spleen, and other organs in a less 
degree, are apt to get more or less closely studded with opaque fibroid 
patches which may attain a thickness of ^ inch or more, and present an 
almost cartilaginous consistence and aspect. 

In many cases peritonitis becomes suppurative. Sometimes, as in the 
puerperal variety, the inflammation presents this character universally and 
from the beginning; the effused lymph is more abundant, opaque, yellow, 
and pulpy than in non-suppurative cases, and obvious pus is poured out 
into the peritoneal cavity. Where inflammation results from the perfora- 
tion of some viscus or sac and the escape of irritating matters, general 
peritonitis of the ordinary adhesive character is often at once excited, and 
thus the effused matters become confined to some limited district. In such 
39 



610 



DISEASES OF THE DIGESTIVE ORGANS. 



cases a circumscribed abscess frequently follows which may possibly under- 
go cure by the discharge of its contents either externally or into the 
bowel. But in some cases groups of such abscesses form ; and sinuses 
extend in various directions — either among the peritoneal adhesions, or in 
the substance of the mesentery, meso-colon, great omentum, and other 
such parts ; and fistulous openings may be established in various situations. 
General suppurative peritonitis may of course result from the escape of 
fecal or other irritant matters into the peritoneum, especially if the escape 
be sudden and profuse ; in which case if the accident be not immediately 
fatal the false membrane becomes exceedingly thick and tough, and the 
general surface acquires the usual characters of that of a chronic abscess. 

Occasionally in peritonitis, as in other serous inflammations, copious 
hemorrhage from the newly-formed vessels of the adhesions takes place 
into the serous cavity. 

Symptoms and progress — The symptoms of peritonitis are mainly those 
of fever in combination with acute abdominal pain, increased by pressure. 
They are liable, however, to considerable variety ; and many others of 
more or less importance are usually superadded. The phenomena of peri- 
tonitis differ greatly, indeed, in relation to the extent and intensity of the 
inflammation and to the circumstances under which it arises. 

Acute idiopathic peritonitis, although by far the least frequent variety, 
yet displays the symptoms and course of the disease in their simplest and 
most typical form. Its mode of onset varies. Sometimes the outbreak of 
the local affection is preceded by a few days of vague sense of illness ; some- 
times it is marked by the occurrence of febrile symptoms, and even of 
rigors ; sometimes the first indications of disease are sudden vomiting or 
purging, or both, or gradually increasing dysuria, or in females the occur- 
rence of menorrhagia. But, whatever the initiatory symptoms, the patient 
before long complains of more or less marked febrile disturbance, and, of 
burning, aching, pinching, or cutting pain, probably limited to some region 
of the abdomen, and increased by pressure or movement. The pain is 
usually in the first instance across the lower part of the abdomen ; and if 
the patient have not yet taken to his bed, he sits, moves, and walks with 
his body bent into a stooping posture. Soon, however, the signs of perito- 
neal inflammation extend and increase in severity; and at the same time 
the patient's general symptoms assume a more serious aspect. The abdo- 
minal pain becomes exceedingly severe, and is aggravated beyond endur- 
ance by the slightest movement. He takes to his bed, where he lies 
motionless on his back; with his head and shoulders elevated, and his 
thighs and legs flexed so as to diminish as far as possible the pressure of 
the abdominal walls on the internal organs ; and breathing by means of 
the intercostal muscles only, and shallowly, with the same object. He \ 
not only shrinks from the pressure of the hand, but generally cannot 
endure even the weight of the bedclothes, or of the poultices or fomenta- 
tions which may have been ordered for his relief. The pain often is com- 
paratively trivial so long as perfect rest is maintained; but it breaks out 
afresh whenever a cough, sneeze, hiccough, or deep inspiration takes place, 
and is liable to periodical and in many cases frequent aggravations, due 
to the peristaltic movements of the bowels. In association with these 
phenomena there is generally distinct fever. The temperature may reach 
104° or 105°, but is very often not above 100° or 101°. The skin is 
hot and dry; the face flushed ; the pulse increased in frequency and sharp- 
ness ; the respirations augmented to 30 or 40 in the minute ; and the tongue 



PERITONITI S. 



Gil 



more or less coated and clammy, if not dry. Vomiting is often present, 
but is no necessary feature of the disease ; and thirst is usually complained 
of. The bowels are generally constipated, but are not unfrequently loose. 
The urine is scanty, high-colored, and sometimes retained ; or there may 
be irritability of the bladder with painful micturition. It may be observed : 
that the presence of marked intercostal respiration indicates involvement 
of the upper part of the abdominal cavity; and that interference with 
micturition points to implication of .the pelvic peritoneum. Further, there 
is reason to believe that the occurrence of vomiting or diarrhoea is refera- 
ble in some cases to inflammation of the serous surface of the stomach or 
bowels. If the disease take a favorable turn, which indeed at the end of 
a few days it usually does, the severer symptoms gradually remit : abdo- 
minal pain and tenderness subside, vomiting ceases, the respirations 
become natural, and the temperature and pulse return to their normal con- 
dition. If, on the other hand, the case be about to prove fatal, important 
changes in the symptoms more or less quickly supervene ; the abdomen 
becomes distended, partly from effusion of fluid, mainly, however, from 
accumulation of gas in the intestines; pain and tenderness, though some- 
times continuing and even becoming aggravated, very frequently undergo 
great diminution and sometimes cease entirely ; sickness probably increases, 
and hiccough supervenes ; the temperature falls, the extremities get cool 
or cold, the face pale or livid, and pinched and anxious in expression, and 
the skin suffused with cold sweats ; the pulse increases in frequency, rising 
it may be to 130, 140, or 160 in the minute, and gets small, thready, and 
weak; the respirations quicken, reaching, perhaps, 40 or even 60 in the 
minute ; and the tongue becomes more thickly coated, and this and the 
lips dry. The patient, in fact for the most part retaining his conscious- 
ness, falls rapidly into a state of profound collapse, in which he presently 
dies. Sometimes more or less delirium comes on before the fatal event, 
and death may then be preceded by coma. 

The tendency to failure of circulation and to collapse is one of the most 
remarkable characteristics of peritonitis, as it is of enteritis. And it is 
important to bear this fact in mind ; for even in the early stage of the 
disease, when the pulse is little accelerated, and sharp, and perhaps strong, 
and the patient appears to be suffering from what is termed ' the sthenic 
form' of peritonitis, a little over-exertion, some unwonted effort, may 
readily induce dangerous collapse. 

It may be added that, while the presence of dropsical effusion adds to 
the distension of the abdomen, it does not, as a rule, materially aggravate 
the danger of the case ; and that, if sufficiently abundant, it may be de- 
tected either by its causing dulness and bulging in the flanks, or by the 
presence of fluctuation ; and further, that peritoneal inflammation con- 
stantly causes basic pleuritis, which may possibly be recognized during 
life ; and that peritoneal friction may also occasionally be detected either 
by the fremitus it occasions or by auscultation. Death may occur as early 
as the second or third day of the attack, or may be delayed to the end of 
a week or ten days. When, however, the disease is prolonged beyond this 
date, it usually lapses into the chronic condition ; in which, either in- 
flammation of little intensity is kept up by the development of tubercles 
or some other cause, or the chronic symptoms are due to the formation of 
a circumscribed abscess. 

Puerperal peritonitis differs from the idiopathic affection chiefly in the 
circumstances under which it arises, in its usually rapidly fatal course, and 



612 



DISEASES OF THE DIGESTIVE ORGANS. 



in the fact that it is often associated with, if not dependent upon, pyaemia 
taking its origin in inflammation of the uterine mucous membrane. It 
generally begins within a few hours or a few days after parturition, with 
severe rigors, attended with high elevation of temperature, and soon fol- 
lowed by intense pain across the lower part of the belly, and suppression 
or modification of the lochial discharge. The main points in its symp- 
tomatology, by which it differs from the simple form of the disease, are the 
speedy supervention of collapse, and the more general and early implication 
of the sensorial functions. Further, the symptoms are, in many cases, 
compounded of those of the local affection and those of pyaemia. 

Peritonitis from perforation is one of the most common and interesting 
forms of the disease, and by far the most fatal of them. When perfora- 
tion takes place in a person who appears to have been, up to the very 
moment of the accident, in the enjoyment of good health — as sometimes 
happens in cases of penetrating ulcer of the stomach, rupture of the urinary 
bladder, or perforation of the ileum in mild enteric fever, the symptoms 
usually are : sudden and intense pain in the region of the lacerated organ, 
speedily followed by all the local indications of violent peritoneal inflam- 
mation ; and extreme and immediate collapse, shown by pallor and cold- 
ness of surface, cold sweats, scarcely perceptible pulse, fainting, and 
vomiting. In some cases the patient dies of this primary collapse in the 
course of a few hours ; and there may be little in the history or symp- 
toms of such a case to distinguish it from one of Asiatic cholera, fatal be- 
fore the supervention of diarrhoea ; or from one of sudden effusion of blood 
into the stomach and bowels, fatal without haematemesis or melsena; or from 
one of ruptured heart or internal aneurism. But more frequently the 
patient rallies somewhat, and the collective symptoms of inflammation, 
fever, and peritoneal mischief become more clearly developed. Collapse, 
however, generally soon reappears, and the patient usually sinks after a 
period varying between twelve hours and two or three days. But the 
symptoms of perforative peritonitis are not always so intense and strik- 
ing. Indeed, they are very often exceedingly difficult of recognition, 
and vague, when they occur in the course of abdominal diseases, whose 
proper symptoms tend to mask them : for example, dysentery, enteritis, 
and those rare cases in which peritoneal suppuration causes perforation of 
the bowel from its serous aspect. By far the most common cases of masked 
perforative peritonitis are those which occur in the second or third week 
of severe enteric fever, when the patient is prostrate with diarrhoea, and 
is dull, confused, and delirious, and to a large extent insensible to painful 
and other impressions. The evidences of perforation are then to be sought, 
not so much in obvious sudden collapse or intensity of abdominal pain, as 
in the general indications of failing strength — namely, increased weakness 
and rapidity of pulse, coldness of extremities, lividity of face, and dimi- 
nution of intelligence, and of power over the limbs and sphincters ; and 
in the supervention or increase of tympanites, with general abdominal 
tenderness, as shown by the expression and actions of the patient when 
pressure is made upon the surface of the abdomen. But although peri- 
tonitis from perforation is a well-nigh hopeless affection, there is reason to 
believe that it is not entirely hopeless. We have known of a case in which 
the patient certainly survived the accident for a fortnight ; and several 
cases have been put on record in which there are good grounds for believ- 
ing that a cure was effected after the formation of an abscess and its dis- 
charge by the bowel or some other route. 



PERITONITIS. 



613 



Peritonitis is not always the serious disease which has been above de- 
scribed. In a large number of cases it is, even if general, slight ; and in 
a large number of cases, also, it is of local origin, and continues localized. 
The symptoms of partial peritonitis are the same in kind as those of the 
more general and more severe affection ; but the local indications are 
limited to some comparatively small area, and the general symptoms, if 
there be no serious complications, are comparatively slight. 

It must not be forgotten that the adhesions which- peritonitis leaves 
behind are not unfrequently a source of discomfort or danger. In some 
cases the compression of the bowels which they induce keeps up a ten- 
dency to colicky pains and intestinal disturbance ; in some cases slowly 
contracting adhesions gradually compress a length of bowel and render 
it practically impervious ; while in other cases, again, bridles or bands are 
formed, behind which coils of bowel are apt to slip and get incarcerated or 
strangulated. 

Peritonitis is liable to be confounded both with enteritis and with 
colic ; but is generally distinguishable from enteritis by the absence of 
intestinal obstruction, and from simple colic by the fact that the latter is 
unattended with fever, and that its pain is usually relieved in some degree 
by pressure. 

Treatment The principles of treatment in peritonitis are sufficiently 

simple ; they are, the maintenance of perfect rest, the administration of 
opium, and the application of leeches and ether remedial agents to the 
surface of the abdomen. The patient should be placed and propped up in 
that position which he finds easiest, usually upon his back, with his knees 
and shoulders elevated. His abdomen should be defended from the weight 
of bed-clothes by means of a suitable cradle. Opium or morphia should 
be given sufficiently frequently, and in sufficiently large closes, to assuage 
the patient's pain and keep it in abeyance, to quiet the action of the 
bowels, and to promote comfort and sleep ; it may be given by the mouth 
or by subcutaneous injection. If the case be severe and in an early stage, 
from ten to thirty or forty leeches should be applied to the surface of the 
abdomen ; and bleeding should be promoted by fomentations or light poul- 
tices. Subsequently hot fomentations, turpentine epithems, mustard plas- 
ters, or blisters may prove serviceable. On the other hand, cold applica- 
tions — evaporating lotions, cold compresses, and ice-bags — have been 
largely advocated, and in many cases have proved of great advantage. 
It is important, moreover, in many cases, to relieve accidental complica- 
tions, such as nausea and vomiting, dysuria, and the like. To meet the 
former indications, recourse must be had to ordinary anti-emetic measures ; 
to meet the second, the catheter may need to be employed. It is, of course, 
essential to maintain, as far as we possibly can, the patient's bodily strength; 
for which purpose nourishing diet, mainly in the fluid form, must be fre- 
quently administered in small quantities, and alcoholic stimulants, in 
amounts depending on the condition of the patient, combined therewith. 
If he cannot retain food on his stomach, it must be given by the rectum. 
It need scarcely be said that cases of peritonitis passing rapidly into col- 
lapse, and especially, therefore, cases of puerperal peritonitis, bear deplet- 
ory measures less well than others ; and hence such treatment is admissible 
only in quite their early stage. These cases, moreover, demand, more 
than others, early and considerable stimulation ; and ammonia and ether, 
or similar agents, may be employed in addition to alcohol. When perito- 
nitis is caused by perforation, our main reliance must be placed upon 



614 



DISEASES OF THE DIGESTIVE ORGANS. 



opium ; and here, especially, it is of vast importance that the movements 
of the bowels be restrained, that purgatives be rigorously avoided, and 
that the stomach be not overloaded with nutriment. If the patient sur- 
vive for two or three days, some hope (remote, no doubt) may be enter- 
tained of his final recovery. But in order to promote this consummation, 
it is always desirable to investigate carefully from day to day the condition 
of the abdomen in order to detect the presence of any circumscribed ab- 
scess there, and as, soon as may be to evacuate its contents. 



IX. CIRRHOSIS OF THE STOMACH AND BOWELS. 

Morbid anatomy Fibroid infiltration or thickening — a condition also 

termed ' cirrhosis,' and having a close anatomical relation with cirrhosis 
of the liver — occasionally takes place in the walls of the stomach and in- 
testines. Thickening, which differs little, if at all, from this, is usually 
present in the neighborhood of chronic ulcers of the stomach. When oc- 
curring independently, all the coats of the stomach, as a rule, are impli- 
cated, but more especially the muscular coat and the submucous tissue — 
the mucous surface being thrown into prominent folds over the affected 
area. The whole stomach is sometimes thus diseased, and is then usually 
diminished in size, tough, and retaining its form like an India-rubber 
bottle. But commonly the affection is limited to the neighborhood of the 
pylorus, which then becomes constricted, and leads to general dilatation of 
the organ. The gastric walls, especially at the pyloric end, sometimes at- 
tain a thickness of half an inch or an inch, and present to the naked eye 
most of the usual characters of scirrhus. The morbid growth, however, 
differs from scirrhus in consisting wholly of fibroid tissue, and not posess- 
ing malignant properties. The intestines are much less frequently affected 
than the stomach. 

The symptoms referable to cirrhosis are exceedingly vague. They re- 
semble, indeed, for the most part, those of the early stages of carcinoma. 
When the pylorus is obstructed, the symptoms of that condition necessarily 
manifest themselves ; when the large intestine is involved, the phenomena 
of stricture presently supervene. 



X. TUBERCLE. {Abdominal Phthisis.) 

Morbid anatomy Tubercular disease of the mucous membrane of the 

stomach is so rare, and so little is known about it clinically or otherwise, 
that it is needless to do more than record the fact of its occasional occur- 
rence. 

1. Boivels. — The mucous membrane of the bowels, on the other hand, 
is one of its most frequent seats ; and, indeed, intestinal ulceration is, in 
a very large proportion of cases, of tubercular origin. Tubercle of the 
bowels occurs in rather more than one-half of the total number of cases of 
pulmonary phthisis, and rarely, if ever, independently of it ; it is frequently 
associated, also, with tuberculosis of the peritoneum and other abdominal 



TUBERCLE. 



615 



organs. It affects primarily Peyer's patches and the solitary glands ; and 
in the small intestine, therefore, is always most abundant and most ad- 
vanced immediately above the ileo-caecal valve, from whence upwards, 
even though it extend throughout the whole ileum and jejunum, it grad- 
ually diminishes. It attacks the caecum more frequently than any other 
part of the large intestine, involving also the ileo-caecal valve and vermi- 
form appendage ; but it may form patches throughout the whole length of 
the colon. The large and small intestines are affected with equal fre- 
quency, and are affected conjointly about twice as often as each is affected 
separately. The tubercles appear as gray granules, or yellow cheesy 
masses, in the substance of the glands, and generally soon undergo soften- 
ing, producing small, deepish ulcers, with thickened, overhanging edges. 
When several tubercles have softened side by side, as occurs in Peyer's 
patches, the ulcerated area presents in the first instance a kind of honey- 
combed appearance — the small ulcers being separated from one another by 
bridles of thickened mucous membrane ; and the general margin, which is 
also thickened, presents a sinuous or scalloped outline. Tubercular ulcers 
generally tend to spread by the successive formation and softening of tuber- 
cles at their edges ; and thus often creep over a considerable area. The 
whole mucous lining of the caecum is sometimes destroyed in this manner; 
and extensive tracts of ulceration often stud the surface of the colon, at 
more or less distant intervals. In the small intestine tubercular ulcers have a 
remarkable tendency to spread transversely, and frequently form bands, from 
half an inch to an inch or more wide, occupying the whole circumference. 
In most cases the ulcerative process progresses up to the patient's death, 
and occasionally leads to serious hemorrhage or to perforation. Sometimes 
the ulcers cicatrize more or less perfectly — some, indeed, cicatrizing while 
others are spreading or new ones forming. Tubercular cicatrization is 
very apt to lead to considerable contraction of the bowel and even to the 
production of stricture. Sometimes, again, tubercles dry up or get ab- 
sorbed without undergoing ulceration, leaving behind them pigmented 
cicatrix-like patches which have some resemblance to the scars left in the 
skin by superficial lupus. It may be added that extensive ulceration of 
the large intestine, presenting all the characters of chronic dysenteric ulcer- 
ation, is often met with in cases of chronic phthisis, where there is no dis- 
coverable tubercle in any part of the bowels except the ileum, and where, 
therefore, it maybe a question as to whether the ulceration is of tubercular 
origin, or has arisen in mere non-specific excoriation such as might be 
caused by the constant passage of irritating secretions from the tubercular 
bowel above. 

2. The -peritoneum and abdominal lymphatic glands are often affected. 
Generally in cases of tubercular ulceration of the bowel, and certainly in 
all cases of extensive ulceration, gray granulations, in greater or less abund- 
ance, stud the serous surfaces corresponding to the diseased areas. But 
such formations are for the most part purely local, and of little importance. 
There are other cases, however, far less common, yet not unfrequent, in 
which the tendency to the growth of the tubercles is general throughout 
the serous membrane, and in which ulceration of the bowel is not only 
their starting-point, but often altogether absent. Peritoneal tuberculosis 
is almost always associated with similar disease of other parts ; most com- 
monly with pulmonary phthisis, but not unfrequently with tubercular affec- 
tion of the bowels and other abdominal organs. It complicates a very 
large proportion of those cases in which the pleurae, spleen, liver, kidneys, 



616 



DISEASES OF THE DIGESTIVE ORGANS. 



uterus and Fallopian tubes, or brain is involved. Peritoneal tubercles are 
sometimes miliary and gray, and from the size of a poppy-seed downwards. 
Sometimes they form lobulated masses from the bulk of a tare up to that 
of a hazel-nut — presenting for the most part an opaque buff color, often 
mottled with black points or patches ; and exhibiting a cheesy aspect and 
consistence, which are modified by the greater or less abundance of fibroid 
material which invests and permeates them. Sometimes, again, but much 
more rarely, there are found, lying between organs which are adherent, 
tubercular laminas of considerable thickness and extent. Peritoneal tuber- 
cles, indeed, rarely exist independently of the effusion of lymph and the 
presence of false membranes. The larger tubercular masses are usually 
comparatively few in number ; the miliary tubercles, on the other hand, 
are, as a rule, thickly set and innumerable. Further, in the latter case 
the peritoneal surface is often found covered with a layer of grayish, trans- 
parent, adherent, and toughish lymph, which not only invests the abdominal 
organs, but unites them more or less with one another, and in the sub- 
stance of which tubercles are disseminated as opaque grains. 

In association with the presence of tubercles all the usual phenomena 
and sequelae of simple inflammation, such as streaky redness, fibrinous 
effusion, and dropsical accumulation, are apt to manifest themselves ; some- 
times, also, suppuration, sometimes profuse hemorrhage. Further, it oc- 
casionally happens that, during the progress of peritoneal tuberculosis 
involving the intestinal walls, perforation of the latter takes place. The 
most important of these phenomena from its frequency is undoubtedly ascitic 
effusion. 

The abdominal lymphatic glands are a frequent seat of tubercle; mainly, 
however, the glands of the mesentery, and more especially those of them 
which are in relation with tuberculous intestine. Tubercle of these organs 
is mostly secondary to tubercle either of the intestines or of the peritoneum. 
It appears in them, and for the most part in their peripheral portions, in 
the form of minute, hard, gray points, which occur in groups and tend 
gradually to run together, and to form imbedded masses which soon undergo 
caseous change. Glands thus affected may suppurate and even rupture 
into the peritoneal cavity ; or they may get slowly converted into mortary 
or calcareous lumps. Tubercular glands are usually more or less enlarged, 
sometimes, indeed, attain the size of a pigeon's egg. When, however, 
they undergo calcareous change they contract and become invested with 
an indurated capsule. Tubercular mesenteric glands sometimes, especially 
in children, collectively form masses easily detectable through the abdomi- 
nal walls ; but there is little doubt that most of those cases of extreme 
enlargement of these glands whicli were formerly regarded as tubercular 
were really cases of lymphadenoma or some other form of malignant dis- 
ease. 

Symptoms and progress 1. Bowels The symptoms of tubercular 

ulceration of the mucous membrane are in no degree specific ; but they 
vary acccording to the part of the bowel which happens to be affected. 
When the disease is limited to the ileum there is probably more or less 
pain and tenderness in the region of the csecum, with frequent griping. 
The bowels may be confined or loose, but are more often, perhaps, irregu- 
lar. When the large intestine is involved, the symptoms closely resemble 
those of chronic dysentery, and, indeed, are by no means necessarily dis- 
tinguishable from them. The points of chief clinical importance in refer- 



TUBERCLE. 



617 



ence to intestinal tuberculosis are : first, that the disease is for the most 
part a progressive one, and that hence diarrhoea having once declared itself 
tends to become progressively more and more severe and intractable ; 
second, that during its progress the patient rapidly undergoes extreme 
emaciation, becomes excessively feeble, and suffers in an aggravated form 
from night sweats, imperfect circulation (indicated by blueness of nose and 
coldness of extremities), and the other phenomena which attend rapid 
impairment of nutrition ; and, third, that it is usually associated with 
well-marked indications of tubercular disease in other organs. Hemorrhage, 
perforation, and stricture are not special to tubercular ulceration, and their 
symptoms need not now be discussed. 

2. Peritoneum The symptoms which attend the progress of peritoneal 

tuberculosis present much variety and are often vague and misleading. 
Often, indeed, and not only in those cases in which the peritoneal affection 
is slight, or in those in which it is as it were overshadowed by the pre- 
ponderance of disease in other parts, but in those cases in which it is the 
predominant or sole affection, they fail to indicate clearly the peritoneum 
as the seat of disease. Further, they are so generally complicated with 
symptoms due to coexisting tubercular disease in other organs, especially 
the lungs, pleura?, and intestines, that it is impossible altogether to dis- 
sociate them from the latter. Most cases of tubercular peritonitis, attended 
with obvious symptoms, may perhaps be somewhat roughly arranged in 
two classes: the first (the acute class), in which the symptoms have a close 
resemblance to those of enteric fever ; the second (the chronic class), in 
which the symptoms correspond for the most part with those of chronic 
peritonitis. 

In the acute form the patient, sometimes in the midst of perfect health, 
more often after an indefinite period of languor and loss of flesh and 
strength, begins to manifest febrile symptoms attended with remissions, 
and indicated by heat and dryness of surface, quickened pulse, pains in 
the limbs, loins, and head, diminution of the secretions, and perhaps 
drowsiness. At the same time probably the abdomen becomes hard, tumid, 
and tender, and more or less uneasy or painful. Generally, also, there is 
some disturbance of the digestive functions — dryness or furring of the 
tongue, thirst, loss of appetite, nausea or sickness, and constipation, diar- 
rhoea, or irregularity of bowels. And possibly, with no material change 
in his symptoms beyond what may be due to increasing debility and emaci- 
ation, and the gradual supervention of 'typhoid symptoms,' the patient 
gradually sinks, and at the end of a few weeks dies. Among the chief 
points by which this affection may be distinguished from enteric fever are : 
the absence of rash, and of pain specially limited to the caecal region ; the 
probable presence of tubercular disease in other organs ; and the fact that 
the temperature, although it may be considerably elevated, does not present 
that regularity of morning remissions and evening exacerbations which are 
! so characteristic of enteric fever. 

j In the chronic variety of peritoneal tuberculosis, the disease sometimes 
, commences with more or less typical symptoms of acute peritonitis; some- 
times it creeps on with the utmost insidiousness ; but in either case the 
j symptoms gradually merge into those of chronic peritonitis, with which 
I (unless our diagnosis be aided by the discovery of tubercular disease else- 
! where) we cannot well avoid confounding them. During the progress of 
j the disease a more or less diffused tumor is apt to be developed — due for 



l 



618 



DISEASES OF THE DIGESTIVE ORGANS. 



the most part to thickening of the great omentum — which may suggest the 
formation of a circumscribed abscess or malignant growth. This sometimes 
forms a transverse bar, in a line with or above the umbilicus. Ascites is 
very apt to ensue. The duration of chronic tubercular peritonitis may vary 
from a month or six weeks to a year or two. 

Tubercular peritonitis tends, as a rule, to a fatal result ; at the same 
time, there are good grounds for the belief that recovery occasionally 
ensues. 

Treatment — The general treatment of abdominal tuberculosis is iden- 
tical with that of pulmonary phthisis and generally of scrofulous disease. 
It comprises careful attention to hygiene, removal, if need be, to a more 
suitable climate, a good wholesome and nutritious dietary, and the use of 
cod-liver oil, iron, and vegetable tonics. If the mucous membrane of the 
bowels be specially affected, and the patient be suffering from exhaustive 
diarrhoea, treatment must of course be specially directed to relieve this 
condition. For the details of treatment in this case, we must refer the 
reader to the articles on intestinal ulceration and dysentery. When the 
peritoneum is the part principally involved, abdominal pain may need to 
be relieved by the application of counter-irritants, fomentations, or even 
leeches ; sleeplessness, weariness, and pain may require to be overcome 
by the use of opiates or other sedative or narcotic medicines ; and further, 
nausea, sickness, diarrhoea, and intestinal obstruction may all in turn call 
for relief by the various measures on which in such conditions reliance is 
usually placed. 



XI. TUMORS. 

A. Non-Malignant Tumors. 

These are not uncommon, but, on the whole, are of little medical 
importance. 

Pedunculated fibrous tumors or 'polypi are sometimes very small, very 
numerous, and of wide distribution throughout both the small and the 
large intestines. Sometimes, on the other hand, they are few in number 
or solitary, and then often attain large dimensions. The latter are occa- 
sionally observed in the ileum, but chiefly affect the lower part of the 
rectum. In the former situation they are believed to be in some cases 
the determining cause of intussusception ; in the latter, they often pro- 
duce irritation, bleeding, tenesmus, and other discomforts. Those only 
can be diagnosed and treated which are within reach, and for them re- 
moval is the only effectual remedy. 

Villous growths are in many cases malignant. Some, however, and 
especially such as are met with in the large intestine, appear to be non- 
malignant. These usually occupy a limited and well-defined area, and 
sometimes encircle the bowel. The intestinal walls in the situation of the 
growth, and especially the mucous and submucous coats are generally 
much thickened ; and from this thickened area as a base, close-set, elong- 
ated, complex villi take their origin. These growths frequently cause 
hemorrhage, which is occasionally serious ; and diarrhoea, which is some- 
times of a dysenteric character. When situated near the anus, they may 
be removed by operation. 



TUMORS. 



619 



B. Malignant Tumors. 

Morbid anatomy. — Malignant growths commence, sometimes in the 
mucous membrane of the stomach or intestines, sometimes in the peritoneal 
tissue, sometimes in the mesenteric or retro-peritoneal glands. In the first 
case, the disease usually takes its origin at some particular spot ; whence 
it spreads over a greater or less extent of the contiguous mucous membrane, 
then gradually involves the whole thickness of the parietes, and having 
reached the serous lamina, diffuses itself in a greater or less degree over 
it, and further implicates the mesenteric or other glands. In the second 
case, the growth tends rapidly to generalize itself over the surface of the 
serous membrane, and to infiltrate the subserous tissue ; but it is often a 
long time before it penetrates the muscular wall of the stomach or bowels. 
Sooner or later, however, this is invaded at points, and then the mucous 
membrane becomes involved. The lymphatic glands necessarily also 
suffer. When the disease begins in the mesenteric or retro-peritoneal 
glands these gradually enlarge ; and presently the morbid growth extends 
from them into the surrounding connective tissue, infiltrates it, and thence 
spreads to the serous membrane, on the one hand, and to the intestinal 
walls on the other. It will thus be seen that, although the site in which 
malignant disease commences exerts a more or less important influence 
over its distribution and consequences, the ultimate tendency is in each 
case to its general diffusion. 

1. Scirrhous cancer, originating in the walls of the stomach or bowels, 
causes thickening and induration of the parts which it affects. If it at- 
tack the submucous tissue, this becomes greatly hypertrophied ; and pres- 
ently the superjacent mucous membrane getting incorporated with it, its 
natural structure gradually disappears, and its free surface, at first perhaps 
thrown into rigid folds, grows irregular and nodulated. Whilst this pro- 
cess is going on, the muscular wall becomes invaded ; the morbid growth 
extends along the intermuscular septa, converting them into irregular but 
thick vertical scirrhous bands, and the muscular tissue thus divided into 
strands at first hypertrophies, and subsequently undergoes fatty degenera- 
tion. At length the subserous and serous tissues get implicated ; they, 
like the mucous tissue, become dense, hard, and thick, and small wheal - 
like excrescences or nodules spring up upon the free surface. Sooner or 
later in the progress of the case, erosion and destruction of the affected 
mucous membrane takes place, and a smooth excavated ulcer results ; in 
some cases sloughs form, and the destruction is more rapid and irregular ; 
and frequently carcinomatous nodules sprout up from the edges and floor 
of the ulcerated surface. Sooner or later, also, adhesions form between 
the affected viscus and neighboring organs, and along them the morbid 
process may be propagated. 

Peritoneal scirrhus always commences in the form of hard, lenticular, 
white spots, measuring a line or so in diameter, which, though projecting 
above the surface, tend specially to invade the subserous tissue. They 
I! are in the first instance scattered thinly or irregularly, but soon become 
aggregated in parts or generally, and then coalesce so as to form patches 
of various sizes. These may be uniformly smooth, or may still present 
traces in their surface or outline of their mode of development. They 
rarely, however, form outgrowths, and not very often invade subjacent 
organs; rarely, too, do they become more than a line or two thick, except 
where they involve folds or processes of peritoneum. The appendices epi- 



620 



DISEASES OF THE DIGESTIVE ORGANS. 



ploicoe become converted into small hard lumps, the mesenteric and other 
like duplicatures thickened and indurated, and the great omentum con- 
tracted into a thick band, stretching transversely across the abdomen in 
the course of the transverse colon. Scirrhous cancer, indeed, whether 
affecting the gastro-intestinal tube or the peritoneum, tends rather to cause 
contraction and thickening than outgrowth, and thus, as a rule, leads to 
constriction of the cavities or canals which it involves, and especially 
therefore to constriction of the cardiac or pyloric orifice or other parts of 
the alimentary tube. 

2. Colloid cancer most commonly takes its origin in the serous lamina, 
whence it spreads to the mucous membrane. When appearing first in the 
latter tissue, it causes, as other forms of cancer do, more or less consider- 
able thickening, and manifests itself at the surface in the form of scattered 
masses, which have a resemblance either to the wheals of urticaria, or to 
groups of herpetic or eczematous vesicles. Like scirrhus, it invades the 
muscular coat — running along the intermuscular septa, and causing the 
muscular tissue to become thickened and hypertrophied ; then attacks the 
subserous tissue and the serous membrane itself, causing these also to be- 
come thickened ; and finally produces at the free aspect groups of vesicles, 
varying individually, perhaps, from the size of a mustard-seed to a scarcely 
visible point. At the mucous surface the affected patches become eroded 
and excavated, but remain pretty smooth, and discharge in abundance the 
transparent glairy fluid with which the interstices of the cancerous matrix 
are filled. Colloid cancer of the peritoneum, in its early stage, appears in 
the form of groups of vesicles, which are more or less elevated above the 
general surface, and spread sometimes in tortuous and anastomosing lines 
as though taking the course of the lymphatic vessels, sometimes by forming 
scattered, isolated, more or less pedunculated growths. The morbid pro- 
cess tends to spread both in surface and in depth. It always involves the 
sub-peritoneal tissue, which may attain very considerable thickness ; and 
it extends thence most frequently to the muscular and mucous coats of the 
stomach and intestines, less frequently to the substance of the mesenteric 
glands, pancreas, liver, spleen, and other viscera. In extreme cases nearly 
the whole of the peritoneum is affected ; it is then irregularly thickened — 
the various duplicatures being especially hypertrophied, and the great 
omentum either converted into a large lobulated mass, or contracted, as it 
is in scirrhus, into a thick, irregular, transverse band. In the progress of 
the disease erosion of the surface is apt to take place, and the glairy fluid 
which it yields is discharged in some abundance into the abdominal 
cavity. 

3. Encephaloid cancer, when affecting the abdominal organs, is charac- 
terized, as it is elsewhere, by its softness, milkiness, and rapidity of growth. 
If it commence in or beneath the mucous membrane of the stomach or 
bowel, on the one hand it soon invades the mucous and submucous tissues, 
and on the other spreads to the muscular coat, and through this to the tis- 
sues on the outer aspect of the viscus. The extension of the growth both 
in thickness and in surface is usually very rapid, and before long results 
in the formation of a more or less lobulated tumor, which often attains a 
very considerable bulk. The encephaloid mass is of course liable to undergo 
all those interstitial changes to which encephaloid cancer is usually liable ; 
but especially it tends to ulcerate. Ulceration begins, as a rule, early, and 
is almost invariably attended with more or less abundant sloughing of the 
cancerous mass, which becomes consequently deeply and irregularly ex- 



TUMORS. 



621 



cavated. But while this is going on, the edges of the ulcerated chasm 
still furnish lobulated outgrowths, and moreover such outgrowths not un- 
frequently take place from the ulcerated surface itself. In some cases 
encephaloid tumors give rise from their mucous aspect to a pile of highly 
vascular villous outgrowths, constituting the so-called 6 villous cancer.' 
Encephaloid cancer of the peritoneum appears in the form of discrete 
nodular outgrowths, which are small and rounded, and differ from those of 
scirrhus not only in their greater softness but in their greater prominence. 
They are hemispherical, spherical, or pyriform, and often distinctly pedun- 
culated. In its further progress encephaloid cancer presents great varieties. 
In some cases it seems, like scirrhus, to invade more particularly the sub- 
stance of the peritoneal folds and to involve subjacent organs ; and under 
such circumstances we sometimes find the mesentery converted into a 
thick, plicated, cancerous mass, with the cancerous growth extending 
from the mesenteric attachment over the surface of the intestines, or the 
greater or lesser omentum or the subperitoneal tissue of other regions 
affected in like manner and forming more or less distinct tumors. In 
other instances it tends rather to form outgrowths which are sometimes 
small and clustered, sometimes more or less distinct from one another, 
rounded and massive. In the former case the whole peritoneal surface 
may be found beset with small lobulated or bunch-of-currant-like excres- 
cences, and the great omentum converted into a large loose mass of such 
bodies. In the latter case the tumors, though more or less abundant, are 
isolated ; and while many probably are small, others attain the size of an 
orange, or even of a child's head. So far as we know, the melanotic 
variety of encephaloid cancer always manifests itself in the latter form. 

4. Epithelioma affects the rectum and anus exclusively. It is some- 
times of primary origin, sometimes due to extension from the uterus or 
vagina. 

5. Adenoid cancer, or cylindrical epithelioma, which has a close re- 
semblance to encephaloid, is not uncommon in the intestine. It is proba- 
bly more common than any as a primary disease of the mucous membrane, 
and is especially apt to cause stricture. 

6. Sarcomatous and lymphadenomatous growths may be regarded clini- 
cally as mere varieties of encephaloid cancer. Still they present some 
peculiarities of habit. Sarcomatous growths are exceedingly uncommon, 
and arise mainly in the substance of the walls of the stomach, where they 
constitute tumors of considerable size, which tend more or less rapidly to 
ulcerate, and comport themselves generally as do encephaloid tumors, 
Lymphadenoma is especially a disease of the lymphatic glands and tex- 
tures ; and hence when the abdominal organs are its seat, the abdominal 
glands usually reach an enormous volume, and the spleen undergoes more 
or less considerable enlargement. In its further progress the morbid 
growth involves the connective tissue around the already diseased glands ; 
and hence the substance of the mesentery and other similar folds of the 
peritoneum become thickened and infiltrated, and nodular outgrowths 
sometimes appear upon their surfaces. As the affection still progresses 
the morbid growth creeps from the mesenteric attachment on to and around 
the small intestine, confining itself almost, if not quite exclusively, to the 
peritoneal membrane and subperitoneal tissue ; and thus the intestine, 
while remaining pervious and probably healthy as to its mucous membrane, 
becomes converted into a thick-walled rigid cylinder. The large intestine 
and even the stomach may be similarly affected. 



622 



DISEASES OF THE DIGESTIVE ORGANS. 



Whenever carcinoma or any other form of malignant disease affects the 
peritoneum, stomach, or bowels, it may spread by continuity to almost any 
neighboring organ ; and hence the liver, pancreas, and spleen are liable to 
be invaded when the stomach or peritoneum in the vincity is its seat, and 
the various pelvic organs when the rectum is diseased ; and further, the 
mesenteric and retro-peritoneal lymphatic glands, or some of them, when 
secondarily affected, often develop into large tumors. Such tumors are 
produced most rapidly, and attain their largest dimensions, when the dis- 
ease to which they are secondary is some soft form of malignant disease. 

There are certain parts of the gastro-intestinal tube which are more 
liable than others to be the primary seat of malignant disease. They are 
the stomach and certain tracts of the large intestine. Of these the stomach 
is much the most frequently affected ; and, although no portion of its sur- 
face enjoys absolute immunity, there is no doubt that its pyloric extremity 
most frequently suffers. When the cardiac orifice is the seat of disease, 
the adjoining portion of the oesophagus is commonly affected. When the 
pylorus suffers, the morbid process usually encircles that portion of the 
stomach which adjoins it, but very rarely extends into the duodenum. 
The effect of malignant disease upon the stomach is in many cases to cause 
irregular contraction and deformity, and especially to cause stricture at the 
cardiac or pyloric orifice. If the pylorus be alone affected and resist the 
onward transmission of food, the stomach often becomes preternaturally 
dilated ; if, on the other hand, there be impediment to the entrance of food 
from the oesophagus, the organ necessarily shrinks. Of the large intes- 
tine, the parts most liable to suffer primarily are, first, the rectum, and 
second, the sigmoid flexure ; and here, as at the orifices of the stomach, 
the disease tends to circumscribe the tube and to cause stricture. It may 
be added that while all parts of the gastro-intestinal canal are apt to be 
implicated in the progress of malignant disease commencing in the peri- 
toneum or lymphatic glands, the lower part of the rectum is especially 
liable to become involved in the extension of urine, vaginal, or other pel- 
vic growths. Further, it must not be forgotten : that malignant disease, 
whether of the stomach or bowels, may be attended with rupture into the 
peritoneal cavity or the establishment of communications with adjoining 
hollow organs ; that hemorrhage (sometimes profuse), with foul or fetid 
discharges, is apt to take place from the congested or ulcerated mucous 
surface : and that (especially when the peritoneum is largely involved) 
peritoneal inflammation, ascites, or obstruction to the return of blood from 
the lower extremities, frequently supervenes. 

Of the various forms of malignant disease affecting the organs under 
consideration, scirrhus is undoubtedly the most common ; scarcely any of 
them, however, is absolutely rare. Taking all forms together, it may be 
said that they mostly occur after the age of forty — a rule, however, which 
is more absolute as regards primary gastric or intestinal disease than that 
of the peritoneum ; inded malignant disease of the peritoneum (especially 
in connection with similar affection of the ovaries) is not uncommon in 
young adult females. Sex, on the whole, exerts but little influence nu- 
merically. Carcinoma of the stomach is one of the most frequently fatal 
forms of malignant disease. 

Symptoms and progress The symptoms referable to malignant dis- 
ease of the several organs now under review simulate those of the inflam- 
matory (mainly chronic) affections of the same organs. And the differ- 
ential diagnosis between them often depends, less on the presence or 



TUMORS. 



G23 



absence of specific symptoms, than on a careful consideration of the history 
j of the case, and a close observance of the phenomena which it presents, 
and their relation to one another. Thus malignant disease of the stomach 
has many features in common with chronic gastritis and gastric ulcer ; 
malignant disease of the bowels many in common with chronic ulceration 
of the bowels and its various sequelae ; and malignant disease of the peri- 
toneum many which shares with chronic peritonitis, tubercular peritonitis, 
j and, we may add, simple ascites. But malignant disease is always remark - 
i ably insidious in its progress ; and vague symptoms of ill-health, with loss 
i of flesh and strength, usually manifest themselves long before the patient 
! quite recognizes the fact that he is ill, or can quite define the character of 
■ his sufferings. The patient, therefore, is generally ill and often markedly 
cachectic before the specific signs of gastric, intestinal, or peritoneal mis- 
chief reveal themselves. Again, the course of a case of malignant disease 
! is always progressively from bad to worse ; and this progressively down- 
i ward tendency is connected as a rule, not simply with the aggravation of 
the ordinary symptoms due to progressive impairment of function of the 
orgain primarily affected, but to the supervention of complications con- 
J nected with the special properties of malignant disease, such as the in- 
volvement of the liver and other abdominal organs in the morbid growth, 
and the development of disease- in more remote organs. The appearance 
of a tumor and its manifest increase in bulk and change in form, in asso- 
ciation with the various phenomena above enumerated, leave little room 
for doubt. Febrile symptoms, thirst, and dryness or foulness of tongue 
are no necessary accompaniments of the disease. 

1. Stomach. — The special symptom's of malignant disease of the stom- 
I ach are as various as those of ordinary dyspepsia. They comprise mainly 
| loss or capriciousness of appetite, pain, and vomiting. Anorexia is a very 
constant and ordinarily a very early symptom ; but it is very variable in 
its presence, and is sometimes absent from first to last. Occasionally the 
appetite is excessive. Uneasy feelings — weight and fulness — in the region 
of the stomach, are frequently complained of, especially after taking food. 
In most cases, also, there is absolute pain of a more or less intense char- 
acter, variously described as aching, burning, butting, or stabbing, and 
referred either to the epigastrium or interscapular region, or to other neigh- 
boring situations. This comes on in paroxysms, which are probably at 
first 1 few and far between,' but increase in frequency, duration, and sever- 
ity with the progress of the disease. It is often brought on or increased 
by the ingestion of food, or by pressure applied to the .epigastrium. Pain, 
however, like anorexia, is sometimes of little severity, and occasionally 
wholly wanting. Eructation is a common but unimportant symptom. 
Vomiting, however, supervenes sooner or later in the great majority of 
cases. This is mostly caused by the taking of food, and comes on at dif- 
i ferent periods after it ; if the cardiac orifice be contracted the food is usu- 
ij ally returned at once (as in other forms of oesophageal obstruction) by 
j regurgitation ; if the pylorus be affected, the vomiting is often delayed for 
, an hour or two or more than that; when the stomach is irritable, vomiting 
! may (as in gastric inflammation) take place almost immediately after food 
has entered the stomach. The vomited matters in the earlier periods of 
the disease are chiefly altered ingesta combined with mucus and the acid 
secretions of the stomach. Later on (especially if ulceration have taken 
place) small quantities of blood escape from the diseased surface, and, 
mingling with the contents of the stomach, give to the vomited matters a 



624 DISEASES OF THE DIGESTIVE ORGANS. 

sooty or coffee-ground appearance. The persistence of this kind of vomit 
is very characteristic of gastric carcinoma. Profuse discharge of blood, 
with hrematemesis and melsena, occasionally takes place, but is not nearly 
so frequent relatively as it is in cases of simple ulcer. When sloughing 
occurs, the vomited matters are often extremely offensive. It is very 
common, especially when the pylorus is the seat of disease, for them to 
contain sarcinae and the torula cerevisias. The detection of a tumor de- 
pends partly on its size and partly on its situation. A tumor at the cardiac 
orifice or cardiac extremity can rarely be felt, however large or extensive 
it may be ; and one situated in the posterior wall or lesser curvature is 
less easy of recognition than one occupying the anterior surface or the 
larger curvature or the pylorus. The. situation of perceptible tumors varies 
somewhat. They mostly occupy the epigastric or right hypochondriac 
region, but are sometimes found in the neighborhood of the umbilicus. 
Unless they have become firmly adherent to the abdominal walls in front, 
or have blended with the pancreas or other enlarged glands behind, they 
are usually movable to some extent under the abdominal walls, both dur- 
ing the act of forced inspiration and (if the patient is lying down) in ro- 
tation of the body from side to side. They are often irregular in shape, 
generally very hard, and not unfrequently lifted up with the aortic pul- 
sations. They are usually also resonant on percussion. Constipation is 
almost invariably present. The special symptoms which ensue when rup- 
ture of the stomach into the peritoneal cavity takes place, or when a com- 
munication becomes established with the transverse colon, need not be 
detailed. 

2. Bowels The symptoms referable to malignant disease of the bowels 

are yet more vague in their indications than those which attend gastric 
carcinoma. There is generally more or less irregularity of action, some- 
times looseness, sometimes constipation, and it may be the occasional dis- 
charge of mucus or modified blood. At the same time there is often pain : 
partly of a colicky character and connected with unwonted movements of 
certain portions of the bowels ; partly burning, aching, or cutting, and 
referable to some particular region. Malignant disease of the large intes- 
tine, and more particularly that of the sigmoid flexure and rectum, pro- 
duce, as a rule, more or less impediment to the action of the bowels, and 
finally stricture. It is in this particular case also that, associated with 
symptoms of obstruction — preceding them, accompanying them, or follow- 
ing them — mucous, sanguinolent, purulent, and fetid discharges, occasion- 
ally even profuse hemorrhages, occur. Further, if the rectum be the seat 
of disease, the case is apt in its progress to be complicated by the form- 
ation of communications between the bowel, on the one hand, and the 
vagina, bladder, or urethra, on the other. In malignant disease of the 
bowels, equally as in malignant disease of the stomach, the presence of a 
distinct permanent tumor is a fact of capital importance. This may often 
fail of recognition ; moreover phantom tumors, due to accumulation of 
flatus or feces, are in such cases specially apt to arise and disappear from 
time to time and puzzle the physician. When the lower part of the rectum 
is affected, the presence of a tumor may generally be readily detected by 
digital examination. 

3. Peritoneum and glands. — The symptoms of peritoneal and of glandu- 
lar malignant disease are necessarily very various and easy to be mis- 
understood. These affections are in a very large proportion of cases 
associated with similar disease of stomach, bowels, liver, uterus, or ovaries, 



MORBID GROWTHS. 



625 



and not unfrequently supervene upon them; and hence their special symp- 
toms are liable to be confounded with and masked by those of the latter 
lesions. On the other hand, many of the symptoms commonly attributed 
to malignant disease of the stomach and other abdominal organs are strictly 
referable to involvement of the peritoneum and lymphatic glands. Among 
the symptoms which attend the affections now under discussion must be 
enumerated nausea, vomiting, loss of appetite, and constipation, diarrhoea, 
or irregularity of the bowels, together with more or less abdominal uneasi- 
ness and pain. The most significant point, however, is the progressive 
enlargement of the belly with the presence of a growing tumor or tumors. 
These present all varieties of character ; they may occur in any region ; 
may be movable or fixed ; may vary in size and shape ; may be hard and 
resisting, or soft and almost yielding a sense of fluctuation ; and, especially 
when they are developed in the neighborhood of the coeliac axis and supe- 
rior mesenteric artery or over the aorta, may pulsate as distinctly as many 
aneurisms do. And hence, notwithstanding the important evidence which 
their presence furnishes, they may be confounded, at some stage at least 
of their progress, with circumscribed abscesses, hydatid tumors, floating 
kidneys, or even aneurisms. In cases where (even if the malignant growth 
be very abundant) the individual tumors are small, the presence of peri- 
toneal outgrowths may altogether escape detection. We may draw atten- 
tion to the fact that often, when no other signs of tumor are distinguishable, 
the presence of the thickened and contracted great omentum, which has 
been shown to occur so frequently in scirrhous and colloid cancer, may be 
recognized as a more or less irregular transverse bar extending horizontally 
from under the margins of the left ribs across the upper part of the umbili- 
cal region to the neighborhood of the umbilicus. To the above statement 
it must be added : that the peritoneal affection often becomes complicated 
by ascites, by peritonitis of a subacute character, by involvement of the 
gastro-hepatic omentum with obstruction of the vena portoe or common 
bile-duct and consequent jaundice, or by anasarca of the lower extremities; 
and that occasionally also the kidneys get affected, the ureters obstructed, 
or the pelvic organs involved. 

Treatment — The treatment of the above affections can unfortunately 
only be palliative. When symptoms are chiefly referable to the stomach 
they must be treated, and may for a time be benefited, by such measures 
as have been recommended for gastric ulcer. When the intestines mainly 
are involved, diarrhoea may need to be restrained by astringent medicines, 
constipation to be overcome by mild laxatives, such as castor oil and the 
like, or by enemata. And pain, whatever its seat or source, may often be 
relieved by counter-irritation, fomentations, or leeches. Opium in such 
cases is generally invaluable, and in most cases becomes at length indis- 
pensable — relieving discomfort and pain, soothing the mind, and giving 
sleep. The patient should of course be sustained by appropriate aliment 
in sufficient quantities and, if necessary, by stimulants. The quality of the 
j food and the mode of its administration must be determined by the special 
requirements of the case; but generally it should be wholesome, easily 
!' digestible, and administered in small quantities and at frequent intervals. 
Milk, eggs, beef-tea, broths, fish, and the like are among the most suitable 
articles of diet. 



40 



626 



DISEASES OF THE DIGESTIVE ORGANS. 



XII. PARASITIC AFFECTIONS. 

A. Tapeworms and Cyst-Worms. (Cestoda or Tceniada.) 

1. General Account. 

The general term cestoda or taeniada includes tapeworms and cyst- 
worms. Of these, though many species are known to exist, four only are 
of interest and importance to the practical physician. They are the taenia 
solium, taenia mediocanellata, taenia echinococcus, and bothriocephalus 
latus, with their respective cystic representatives. 

All the taeniada pass through two phases of existence. In the one the 
characteristic head or scolex of the animal, developed in connection with a 
cyst or bladder-like body, and devoid of sexual organs, lies imbedded in 
the solid tissues of the host, or creature that harbors it. In the other the 
animal, or rather colony of animals, in the form of a tapeworm or strobilus, 
occupies the alimentary canal. In this condition it still presents at its 
upper extremity a scolex or head by which it adheres to the mucous mem- 
brane, while its tape-like body is divided into a series of quadrilateral ele- 
ments, or proglottides, each of which when mature contains male and 
female organs and must be regarded as a distinct animal. To trace the 
cycle of events in the life-history of the taeniada it will be convenient to 
commence with the ripe proglottides, within which are produced enormous 
numbers of fertile eggs, in the interior of each one of which a peculiar six- 
hooked embryo is developed. These proglottides usually become detached 
from the rest of the strobilus, escape from the anus of the host, and either 
then or previously discharge their ova, which become scattered broadcast. 
Of these fertile ova some find their way sooner or later into the alimentary 
canal of some appropriate animal. Then the six-hooked embryo bursts its 
shell, migrates through the intestinal parietes, and continues its wander- 
ings until it reaches some spot suitable for its further development, where 
it gradually undergoes those changes which result in the formation of the 
perfect cystic scolex. The further fate of this scolex depends mainly on 
that of its host. It cannot migrate, but lies passive in the cavity which it 
forms for itself, and there at length perishes, unless before that occurrence 
its host become the prey of some other animal. In this event the scolex 
enters the alimentary canal, and under the new conditions which then 
surround it at once enters on a new career of life. It fixes itself to the 
mucous surface, it loses its vesicular expansion, and from its caudal ex- 
tremity the strobilus or chain of sexually reproductive proglottides is grad- 
ually evolved. Thus two distinct hosts as a rule are needed for the com- 
pletion of the cycle of existence of these creatures ; the one (usually a 
vegetable-feeder) for the asexual period of its existence, the other (very 
commonly a carnivorous animal) for the period of its sexual activity. It 
follows from the above statements that the ova of the tapeworm, even if 
set free within the alimentary canal, probably never get hatched until after 
their escape from it. Further, it may be regarded as a general rule, that 
the same species of animal is not liable to suffer from both the cystic and 
the sexual forms of the same cestode. Man is in some degree an exception, 
for he is apt to harbor both the taenia sodium and its vesicular representa- 
tive — the cysticercus cellulosae. Looking, however, to the facts that 
patients affected with this tapeworm are not usually also affected with the 



TAPEWORMS. 



627 



cysticercus, and conversely, and that man, moreover, is an omnivorous 
feeder, there is good reason to believe that the exception is apparent rather 
than real, and that he derives the two forms of the parasite in the orthodox 
way from independent sources. 

2. Tcenia Solium. Tcenia Mediocanellata, and JBothriocepkalus Latus. 

a. Tcenia solium and Cysticercus cellulosce — The taenia solium is one 
of the most common of human tapeworms. In its perfect condition it 
usually measures from seven to ten feet long, but often exceeds that length. 
Its head or scolex, which is about as large as a small pin's head, or, to be 
more exact, between J-g and ^ inch in diameter, is succeeded by a deli- 
cate thread-like neck, which, gradually becoming broader and flatter and 
wrinkled transversely, merges ere long in the distinctly -jointed body. The 
joints or proglottides are, in the first instance, much broader than they are 
long ; but gradually with their increase in size this relation ceases ; and 
although they still get broader, their length throughout the greater part of 
the strobilus exceeds their breadth. Towards the lower extremity, the 
quadrilateral joints measure on the average a quarter of an inch wide by 
half an inch long. The globose head presents four projecting suctorial 
disks placed at equal distances upon and a little above the equator ; and 
springing from its pole a rounded elevation, or rostellum, the margin of 
which is furnished with a double circle of hooks. The apparently homo- 
geneous neck may be seen under the microscope to be transversely wrinkled 
at a very short distance from the head. The sexual apparatus first be- 
comes visible about a foot below. It comprises male and female organs 
opening by a common aperture in the lateral edge of each joint — the aper- 
tures of the successive proglottides alternately occupying opposite sides. 
At about two feet from the head the ova become impregnated, and shortly 
afterwards enter the uterus, which occupies a large portion of the body of 
the proglottis, forming a longitudinal central canal with several horizontal 
diverticula on either side. The egg is globular, about T jfu inch in dia- 
meter, presents a remarkably thick brownish shell, both concentrically and 
radially striated, and when ripe contains a six-hooked embryo. 

The taenia solium is essentially an inhabitant of the small intestine, to 
the mucous surface of which it fixes itself by its hooklets and suckers. It 
is usually, as its name implies, solitary ; but two, three, or more are not 
unfrequently associated, and occasionally much larger numbers. From the 
time of its entrance into the bowel until it reaches its full development a 
period of three or four months usually intervenes ; and it may live in the 
bowel for many years, during which time it is constantly shedding its ripe 
proglottides and discharging ova into the alimentary canal. 

The cysticercus cellulosce is chiefly known as a denizen of the flesh of 
pigs, in which it is sometimes present in vast numbers, rendering the pork 
4 measly.' And it is almost exclusively to the use of such pork in an 
uncooked or imperfectly cooked condition that the development of taenia 
solium in the human intestine is due. In the comparatively rare cases in 
which the cysticercus infest the human body it seems to occur mainly in 
the muscles, connective tissue, brain, eye, and serous membranes. It exists 
under the form of a round or ovoid vesicle, about the size of a pea or bean, 
but sometimes attaining that of a marble, formed of a transparent elastic 
membrane containing a clear limpid fluid. Springing from one side of this 
vesicle is a wrinkled cylindrical neck, terminating in a head precisely 



628 



DISEASES OF THE DIGESTIVE ORGANS. 



similar to that of the taenia solium. The neck and head protrude externally 
after death, and may be made to protrude by pressure during life ; but in 
the ordinary living state they are retracted within the vesicle, lying coiled 
up against one side of it. The conversion of the six-hooked embryo into 
the perfect cystic scolex occupies about two and a half months ; and the 
scolex may remain living in the tissues of its host for many years. 

b. Tcenia mediocaneUata, and Cysticercus tcenioz m. c This tape- 
worm, which was formerly confounded with the last, is equally common. 
It presents a general resemblance to it both anatomically and in habit ; 
but it presents also characteristic differences. It attains a greater length, 
its joints are longer and broader, and its head also is about three times as 
thick. The head, moreover, is furnished with four large round pigmented 
suckers, but with neither rostellum nor armature of booklets ; the uterus 
though exhibiting the same general arrangement as that of the taenia solium, 
is characterized by much more numerous and finer transverse processes ; 
and the ova, instead of being round, are oval, the long diameter differing 
little from the diameter of the egg of the taenia solium, the short diameter 
measuring about inch. 

The cysticercus of this tapeworm seems especially to affect the ox, and 
it is, therefore, to the eating of imperfectly-cooked beef that the intro- 
duction of the scolex into the intestines is due. The cysticercus is a small 
oval vesicle, similar to that of the cysticercus cellulosae, but smaller than 
it, and furnished with a neck and head, of which the latter is identical with 
that of the adult sexual strobilus. It is not known to affect the human 
being. 

c. Bothriocephahis latus This tapeworm is limited in its range to 

certain European countries, especially Belgium, Holland, Poland, Prussia, 
Russia, Sweden, and Switzerland. It is the largest of all tapeworms — 
not unfrequently attaining a length of twenty-five feet and upwards, and 
a breadth of more than half an inch at its widest part. The head is ovoid 
in form, measuring about T ^ inch in length by in breadth, and present- 
ing two opposite longitudinal deep grooves or suckers, but no hooklets. 
The neck, which is comparatively narrow, soon becomes transversely 
wrinkled ; and as it widens out and retreats from the head, the wrinkles 
divide it into successive segments. The segments gradually increase 
in all their dimensions, but for the most part continue of greater width 
than length ; and are specially characterized, not merely by their general 
form, but by the facts that the genital pore is placed in the centre of each 
flat surface, and that the uterus forms a small rosette, of which this pore 
is the centre. The ova never become matured within the uterus, and 
usually escape thence into the bowel, while the proglottis is still a portion 
of the strobilus. After the discharge of their ova, the joints diminish in 
size, and become shrivelled and elongated. The eggs are of oval form, 
measuring about inch by - 5 -^, and have a firm brown shell, which 
opens by a lid at one end. The embryo, on its escape from the egg, is 
provided with cilia, which it soon loses, and then presents the common 
six-hooked character. The cysticercus of this tapeworm is at present 
unknown, as also is its habitat. It is generally believed to infest some 
fish or other aquatic animal. 

Symptoms The symptoms to which tapeworms give rise are on the 

whole trivial and unimportant. Many of those who are infested by them 
enjoy perfectly good health ; and many more make them the scapegoats of 
all their ailments (imaginary or otherwise) from which they happen to 



TAPEWORMS AND HYDATIDS. 



629 



suffer during the residence of these parasites within them. Among the 
symptoms which are referred to their presence are : pain and discomfort in 
the belly, capricious appetite, variable condition of bowels, itching at the 
nose and anus, depression of spirits, emaciation, and hysterical, epileptic, 
or other nervous phenomena. The list might easily be extended ; but 
when we consider that, notwithstanding all the evil influences which have 
been attributed to them, they are probably never diagnosed or even sus- 
pected to be present until their joints have been detected in the stools, it 
is obvious how vague and on the whole how apocryphal all these influences 
are. The only way in which the presence of tapeworms can be recog- 
nized is by the discovery of their joints either in the stools or about the 
anus or on the body-linen, and of their eggs by the microscopic examina- 
tion of the feces. 

The cysticercus cellulosse causes no symptoms unless it be lodged in 
some delicate or vital organ, such as the eye or cortex of the brain, and 
even then the symptoms are not specific. 

Treatment Many remedies have been employed for the purpose of get- 
ting rid of tapeworms ; but those on which reliance is now chiefly placed 
are the male fern, the bark of the pomegranate root, kousso, and kamala. 
The liquid extract of male fern may be administered in a dose of from 30 
to 120 minims early in the morning on an empty stomach, and be followed 
shortly by a full dose of castor oil. And if this procedure prove insufficient, 
the treatment may be repeated either on the next day or from time to 
time at short intervals. The other varieties of vermifuge are employed in 
much the same manner. The decoction of pomegranate root is given in 
large quantities — a pint or more, for example — in two or three portions at 
short intervals. Kousso is administered similarly, excepting that the 
powder from which the infusion is made is usually drunk with the infusion. 
The dose of this is from four to eight ounces. These drugs rarely fail to 
bring away large portions of the worm ; but no absolute cure is effected, 
unless the head be brought away as well. This, however, from its small 
size is very apt to escape detection. It is consequently of great import- 
ance to make a very careful inspection of the evacuations which are passed 
subsequently to the administration of vermifuge drugs. In order to pre- 
vent the developement of tapeworms in the intestine, it is necessary that 
flesh, and especially those kinds of flesh which are known to harbor their 
vesicular representatives, should always be eaten in a well-cooked condition. 
Underdone and merely smoke-dried beef and pork should certainly be 
avoided. 

With respect to the cysticercus cellulose, unless it occupies some super- 
ficial part, and thus lies within reach of surgical treatment, we can do 
nothing for the patient's relief. The ova of the taenia solium are probably 
taken into the stomach with uncooked vegetables, salads and the like, and 
hence those who wish to guard against them should content themselves 
with cooked vegetables only. 

3. Tcenia Echinococcas and Hydatid. 

The tcenia echinococcus is only known to affect the dog and wolf, and 
is usually found in them in large numbers, adhering to the mucous mem- 
brane of the duodenum and jejunum. It is peculiar in comprising in its 
perfect form four joints only, and in having a length of little more than a 
quarter of an inch. The first joint is that which includes the head. This 



630 



DISEASES OF THE DIGESTIVE ORGANS. 



measures about inch wide, and is furnished with four suckers, and a 
central rostellum, provided with a double coronet of hooklets, which vary 
from thirty to forty in number. The fourth segment, which is as long as 
the other three joints together, is usually alone furnished with sexual 
organs and a marginal reproductive papilla. The eggs, like those of the 
taenia solium, are globular and thick-walled. 

The cysticercus or larval form of this tapeworm, commonly known as 
an hydatid, is one of the most dangerous to life of all parasites. It differs 
from the cysticerci of other tapeworms in the fact that it is capable, on 
the one hand, of almost indefinite increase of size, on the other, of almost 
indefinite multiplication by the formation of gemmae. Its favorite haunt 
is the liver, next to that the subperitoneal tissue, and then probably the 
lungs, kidneys, and brain. It is found also in the heart, muscles, and 
bones ; and indeed has occasionally been detected in almost every organ 
and tissue of the body. In its early condition it is a small globular cyst, 
with transparent laminated walls and finely granular contents. At a later 
stage the cyst has acquired considerable dimensions, the walls have become 
thick and the contents fluid. The walls are formed of two portions : an 
outer, comparatively thick, which is transparent, elastic, tremulous, and 
beautifully laminated ; an inner, which is thin, delicate, and composed 
mainly of delicate cells, often containing oval or globular refractive bodies. 
The fluid contents are limpid, colorless, of low specific gravity, and pecu- 
liar in containing a considerable quantity of salt, and, as a rule, no albu- 
men. In some cases the hydatid experiences no other change than increase 
of size. Much more commonly, however, it undergoes further develop- 
ment. This consists principally in the formation of other cysts in the 
substance of its walls, sometimes towards the outer aspect, sometimes in 
the mid-region, sometimes towards the inner aspect, and then often in 
connection with the cellular lamina. These secondary cysts in many cases 
repeat in their growth all the characters of the parent hydatid. In many 
they remain permanently devoid of the outer laminated wall. But whether 
they continue thus simple or not, and especially in the former case, their 
contents often undergo gradual conversion into one or several echinococci 
or scolex heads — the cysts then forming what are sometimes termed brood- 
capsules, and remaining permanently of minute, if not of microscopic 
size. The results of these processes going on almost indefinitely are very 
various. Thus, in some cases, an hydatid tumor as large, perhaps, as a 
child's head, consists of one hydatid cyst only, with a larger or smaller 
number of brood-capsules, springing bud-like from its inner surface ; in 
other cases an indefinite production of barren hydatid cysts takes place, 
so that the original cyst becomes filled with innumerable daughter cysts, 
each of which has, like its parent, the capacity for growth and the pro- 
duction of new cysts by gemmation ; in other cases again (and these are 
the most common) the parent hydatid ultimately contains both barren and 
fertile cysts. It occasionally happens : that the hydatids formed in the 
walls of the primary cyst, instead of projecting at its inner surface, and 
finally getting shed into its cavity, project outwards and thus form separate 
tumors; and further, that in the liver the hydatid growth forms a multi- 
locular mass, in which it may be assumed that the walls of the separate 
cysts are, as it were, fused together. 

The scolex or echinococcus in its living condition is a rounded or ovoid 
body, from t Jq to ^ 6 inch in length, attached by a depression at one ex- 
tremity to a cord which fixes it to the wall of the brood-capsule, and pre- 



ROUND WORMS. 



631 



senting at the other extremity an orifice communicating with a central 
vertical canal, at the bottom of which lie the retracted rostellum and 
hooklets, and on the sides of which is seated the inverted suctorial region. 
When the animal is dead all the latter organs are protruded, and the form 
which it then presents is as nearly as possible that of the first joint of the 
taenia ; the small vesicular body is surmounted by a kind of quadrilateral 
expansion, the angles of which are occupied by suckers and from the centre 
j of which arise the rostellum and the crown of hooklets. The latter vary 
\ in length between T yso an( ^ sio inch. The growth of hydatids is for the 
| most part very slow ; they enjoy, however, a long life, often continuing to 
j grow and multiply for five, ten, fifteen years or more, and it may be during 
the whole period of the life (however much prolonged) of their host. In 
I many cases, however, they (like all other imbedded parasites) undergo 
spontaneous dissolution ; in which case the tumors shrink ; the cyst walls 
! get flattened and compressed against one another ; the echinococci break 
j down, shedding their hooklets ; the surrounding tissues become thickened 
and indurated : and an abundant deposition of calcareous matter pervades 
the capsule and even the hydatid mass. 

For the symptoms and treatment of hydatid tumors we must refer to 
the disease of the several organs in which they occur. We need only 
mention here that no drug that we know of given by the mouth is capable 
of affecting these creatures injuriously; and that, in reference to prophy- 
laxis, the chief if not sole source from whence we derive them is the ex- 
crement of dogs. 

B. Round Worms. (N~oematoda.) 

1. General Account. 

These are elongated round worms, presenting a distinct integument 
marked with fine transverse rugas, a perivisceral cavity, a distinct aliment- 
ary canal, provided with a mouth at one extremity, and for the most part 
an anus on the ventral aspect close to the opposite extremity, and sexual 
organs. The sexes are always separate ; in the male (which is smaller 
than the female) the genital pore opens in immediate relation with the 
anus ; in the female, the vaginal orifice is usually situated about the middle 
of the ventral aspect. 

It is certain that some species of this sub-class of parasites need (like 
the tasniada) two successive hosts for the completion of their cycle of ex- 
istence. The trichina spiralis, for example, passes an asexual life imbedded 
in the voluntary muscles of the pig or man ; and there, unless the affected 
flesh become the food of some other animal, after a while it dies. If, how- 
ever, the trichinous flesh be eaten, the cysts in which the trichinae are con- 
tained become dissolved ; the animals are set free, rapidly acquire sexual 
i organs and copulate; ova are developed and fertilized and hatched while 
j still in the uterus ; and the living embryos on their birth, instead of remain- 
, ing in the bowel, undergo an active migration through its. walls, and ere 
long reach the tissues in which they are to become imbedded. As regards 
the ascaris lumbricoides, there is good reason to believe : not only that the 
ova which are shed in vast numbers into the intestinal canal which they 
J occupy are never hatched there ; but that they are taken into the body of 
j some other animal, probably one of the invertebrata, within which (pos- 
sibly imbedded in the parenchyma) they complete one phase of their exist- 



632 



DISEASES OF THE DIGESTIVE ORGANS. 



ence. There is reason even to doubt whether the common threadworms 
multiply in the region which they infest — whether the ova which they dis- 
charge so abundantly become hatched within the anus. Dr. Kansom, in- 
deed, suggests that in many cases (among young children especially) there 
may be a kind of re-infection due to the conveyance of the ova from the 
anus to the mouth by the fingers. 

Among the nematode worms are included the Ascaris lumbricoides, the 
Oxyuris vermicularis, the Dochmius duodenalis, the Trichocephalus 
dispar, the Trichina spiralis, and the Filaria sanguinis hominis, which 
will now engage our attention ; the Filaria medinensis, whose effects are 
surgical ; and several others, including the Strongylus gigas, which are of 
rare or doubtful occurrence in man. 

2. Common Round Worm. {Ascaris Lumbricoides.) 

This well-known worm varies in size ; in the female from 10 to 14 inches 
long, and from i to ^ inch thick ; and in the male from 4 to 6 inches long, 
with a correspondingly small diameter. The worm is cylindrical, tapering 
to either end, white with a brownish or reddish tinge, and invested in a 
firm elastic integument. The ova, of which each female discharges, on 
the average, 160,000 daily, are oval, measuring gi^- inch by inch. 
They have a thick, firm, nodulated shell, and contain, as ordinarily passed 
from the bowel, no trace of embryo. 

This ascaris is found in some few animals besides man. In man its spe- 
cial habitat is the small intestine ; but it is apt to wander, and thus to reach 
the colon, on the one hand, or the stomach, on the other; and, indeed, it 
has been known to find its way into the hepatic or pancreatic duct, and 
also into the nose or larynx. It has been often asserted that it occasion- 
ally perforates the wall of the bowel, and thus finds its way into the peri- 
toneum, or some sinus or abscess. It is now, however, generally held 
that when found in such situations it has simply passed thither through an 
accidental perforation. The number of ascarides present at the same time 
rarely exceeds five or six. But authentic cases are on record in which the 
bowels have been infested with hundreds and even thousands of them. The 
time during which a worm remains a denizen of the bowels is probably 
never more than a few months. 

Sympto?ns. — Innumerable symptoms have been referred to the presence 
of these parasites, as to that of the taenia? ; but there is no doubt that in 
the great majority of cases they give no indication whatever of their pres- 
ence, which is not even suspected until one or more have been discharged. 
The symptoms which might reasonably be referred to them are those of 
intestinal irritation, which in children are always liable to be attended 
with some degree of fever and more or less cerebral disturbance. When 
these worms are harbored in large numbers, there is no doubt that they 
may induce very grave gastro-enteric symptoms, but symptoms which are 
in no sense characteristic. Occasionally too a mass of them causes com- 
plete occlusion of the bowel, as any other concretion may do. In all cases 
where these worms are suspected to be present, and always before a cure 
can be safely announced, the feces should be subjected to microscopic 
examination ; when, if they be present, the innumerable eggs which are 
discharged can scarcely be overlooked. Ascarides are occasionally vomited. 

Treatment Various remedies have been employed with the object of 

getting rid of ascarides, and among them those which are in common use 



WHIP-WORM. 



633 



against tapeworms. The mucuna pruriens also was formerly much es- 
teemed. The remedy now mainly relied upon is santonica, and more 
especially its active principle, santonin, of which from one to three grains 
may be given twice daily to a child, and about twice that quantity to an 
adult. Violent purgatives are of little or no use; an occasional laxative 
may, however, be given with advantage during the course of treatment by 
santonin. 

3. Common Thread-worm or Seat-worm. (Oxyuris Vermicularis.) 

This creature is minute, fusiform, white, and, as its popular name im- 
plies, thread-like. The female varies from ^ to ^ inch in length, and 
presents a comparatively long attenuated caudal extremity. The male is 
about half the length of the female, and its caudal extremity is simply 
fusiform. The ova are oval, but unsymmetrical, measuring inch by 
TToo' They present a firm shell with three laminae, of which one is absent 
at one of the poles. At the time of deposition they contain a developing 
embryo. Thread-worms are probably the most common of all intestinal 
parasites ; they infest persons of all ages, but children much more fre- 
quently than adults. They occur habitually in the colon alone, and indeed 
are limited almost exclusively to the rectum. They are often present in 
enormous numbers. The females are apt to migrate through the anus, 
and to deposit their eggs on the skin and among the hairs in its vicinity ; 
they occasionally also find their way into the vulva, vagina, and urethra. 

Symptoms. — The chief symptom to which oxyurides give rise is trouble- 
some itching about the anus, coming on mainly in the evening ; it is often 
intolerable, especially if they have migrated into the vulva or urethra. 
Children affected with them are said also to suffer from itching at the 
nose ; and many of the functional disturbances which have been attributed 
to the presence of more formidable parasites have also been attributed to 
them. The diagnosis of thread-worms can easily be verified by their dis- 
covery and that of their ova in the feces. 

Treatment — Local measures are usually amply sufficient for getting rid 
of thread- worms. The injection of a strong infiision of green tea, quassia, 
or any other bitter, or of a solution of perchloride of iron or salt, repeated 
if need be from time to time, is usually efficacious ; the use of mercurial 
ointments or other parasiticide applications in and around the anus may be 
serviceable for the destruction of the ova in these situations ; in addition 
to which measures occasional purgatives may be administered, and the 
patient put under a course of tonics. 

4. Whip-worm. {Trichocephalus Dispar.~) 

This is said to be not uncommon. But it is rarely met with in this 
country. It is especially characterized by having a comparatively thick 
cylindrical body, terminating anteriorly in a delicate filiform process, which 
forms about two-thirds of the entire length of the parasite. The male 
measures about one and a half inches long and the female about two inches. 
The latter is very prolific. The eggs are oval, about 5 inch by X joo? 
pointed at either end, and presenting a firm brownish-yellow shell. The 
normal habitat of this worm appears to be the caecum, to which it attaches 
itself by burying its thread-like neck in the substance of the mucous 
membrane. 



634 



DISEASES OP THE DIGESTIVE ORGANS. 



It does not appear to give rise to any symptoms, and, indeed, its pre- 
sence can only be diagnosed by the discovery of ova in the feces. 

No treatment is needed ; the measures most likely, however, to be effi- 
cacious in effecting its disiodgment are those already discussed in relation 
to the ascaris. 

5. Dochmius Duodenalis. {Sclero stoma Duodenale.) 

This is a small cylindrical worm of which the female slightly exceeds 
half an inch in length ; the male is somewhat smaller. It has not been 
met with in this country, but is not uncommon in hot climates. The in- 
habitants of Italy and Egypt are especially liable to be infested with it. 
It appears to take up its abode in the duodenum and upper part of the 
jejunum, where it may be present in vast numbers, fixing itself to the 
villi, sucking the blood, and causing hemorrhages and dangerous (some- 
times fatal) anaemia. 

No efficacious treatment is known. The measures recommended for the 
expulsion of the ascaris may, however, be tried. 

6. Trichina Spiralis. Trichinosis. 

The trichina spiralis was known only as an occasional inhabitant of the 
muscular tissue, and regarded as a mere pathological curiosity, until the year 
1860 ; when a case that came under the observation of Dr. Zenker, of 
Dresden, conclusively showed that, however harmless the encysted parasite 
might be, the gravest symptoms, and even death itself, might be caused, 
after its reception into the bowels, during the process of reproduction which 
ensued there, and of migration of the young animals into the voluntary 
muscles. Since that period the ' trichina disease' or ' trichinosis' has been 
fully recognized and frequently observed. 

The trichina spiralis is met with in the muscular tissue in the form of 
a minute worm, measuring about ^ inch in length. Its anterior extre- 
mity is somewhat pointed, its posterior thick and rounded ; it presents 
immature sexual organs, and lies coiled up in the interior of the oval cyst. 
This cyst, which is no essential part of the parasite, but forms around it 
after it has taken up its quarters, measures about inch in length, is 
thick-walled, laminated, transparent, and generally studded externally, 
especially about the poles, with granular calcareous matter. The trichina- 
cysts occupy the striped muscles of the body, and are often especially 
abundant in those of the larynx. The heart, however, is rarely if ever 
involved. They appear in the muscles as minute white grains distinctly 
visible to the naked eye, of which the long diameter corresponds to the 
direction of the fibres. Their apparent size is usually increased by the 
fact of the development of groups of fat-cells in relation with either extre- 
mity. The numbers present vary, of course, in different cases. In a cat 
experimented upon by Leuckart each ounce of muscle was calculated to 
contain 325,000 trichinae ; and on the basis of this calculation Dr. Cobbold 
estimates that a man of medium bulk may easily harbor 20,000,000. The 
length of time during which these larval trichinae retain their vitality is 
very uncertain. There is no doubt, however, that they may live in the 
muscular tissue for many years, and that they retain life after, the death of 
their host, and even after the putrefaction and disintegration of his tissues. 
They do, however, perish in situ sooner or later, and then usually undergo 



TRICHINOSIS. 



635 



calcareous changes. Trichina? have been discovered in the flesh of various 
animals besides man, but mainly in that of the pig ; and indeed it is from 
the use of trichinous pork that man becomes affected. The trichina-cap- 
sules swallowed with the flesh are dissolved by the gastric juice, and the 
contained parasites are set free. These then undergo rapid development 
and attain sexual maturity — the female ultimately acquiring a length of |- 
inch, the male a length of not more than ^ inch. The ova are hatched 
within the uterus; and the living embryos, escaping thence into the intes- 
tinal canal of the host, at once commence active migration. They attach 
themselves to the mucous membrane, eat their way through the intestinal 
walls, and either continue to burrow through all the tissues which lie be- 
tween them and their destination, or, what is more probable, find their 
way into the small vessels and lymphatics of the bowels, and are thence 
conveyed all over the organism. They have been found during this period 
in almost all parts of the body — in the intestinal walls, abdominal cavity, 
mesentery and mesenteric glands, and connective tissue, and in an as yet 
unencapsuled condition in the muscular tissue itself. 

The progress of events above described is always very rapid. The im- 
mature trichina? taken into the stomach become mature on the second day ; 
on the sixth and following days, up to the end of the second or even third 
week, the embryos are born and commence operations ; they probably reach 
their destination in the course of a week or two, and by the end of a month 
or a little more have come to the conclusion of their labors. 

Symptoms and progress The symptoms which attend the development 

and migration of trichina? are on the whole very remarkable and suggestive 
of the disease. They comprise, in the first instance, those of gastrointes- 
tinal disturbance ; in the next those of general muscular inflammation ; 
and, associated with these, febrile phenomena. 

Within a day or two, or at most a week, after the ingestion of trichinous 
flesh symptoms not unlike those of enteric fever manifest themselves. The 
patient suffers from thirst and loss of appetite, with perhaps nausea and 
sickness ; and from colicky pains in the abdomen, with constipation or 
irregularity of the bowels, or actual diarrhoea. His tongue is coated ; and 
there is more or less mental and muscular prostration, with elevation of 
temperature, and acceleration of the heart's action. These symptoms, 
which are ill-defined in the beginning, become aggravated day by day 
during the first week or ten days of the patient's illness, and in some cases 
culminate in those of fatal enteritis or peritonitis. More commonly, how- 
ever, about the end of this time they undergo some remission and then 
gradually subside. But while they are in progress, and even it may be in 
progress of amendment, other symptoms due to the migration of the para- 
site develop themselves and soon overshadow them. These consist mainly 
in gradually increasing pain and tenderness, swelling and stiffness of the 
voluntary muscles, together with oedema of the subcutaneous connective 
tissue, copious perspirations, and aggravation of debility and febrile dis- 
turbance. The pains have some resemblance to those of rheumatism, but 
they occupy the fleshy parts of the limbs and trunk and not the joints. 
The general stiffness, tenderness, and swelling lead to flexion and immo- 
bility of the limbs, and it may be to impediment to the due action of the 
muscles of the tongue and larynx and of those concerned in respiration. 
Dropsy, which is one of the earliest indications of the migration of the 
parasites, commences in the face, particularly in the eyelids, then attacks 
the extremities, and subsequently probably becomes general, involving 



636 



DISEASES OF THE DIGESTIVE ORGANS. 



even the serous cavities. Hoarseness, or loss of voice, and dyspnoea are 
not uncommon. The temperature presents great differences. In some 
cases it rarely, if ever, rises above the normal. In severe cases, how- 
ever, it may reach 104°, 105°, or even 106°, but then varies greatly and 
irregularly from day to day, and always presents considerable morning 
remissions. 

The total duration of the disease varies. In mild cases the patient 
recovers in the course of a month ; in many cases recovery is delayed to 
the end of six weeks or two months ; and occasionally the patient con- 
tinues ill for three or even four months. The trichinous disease varies 
very greatly in severity — its severity depending mainly on the number of 
living parasites which the patient receives into his bowels. In some 
instances there are few or no symptoms to attract attention ; in some out- 
breaks where many persons have been attacked the mortality has been 
very light ; while in others the death-rate has been twenty or twenty -five 
per cent. Death may result from enteritis, peritonitis, or pneumonia, or 
from the debility which the progress of the disease gradually induces ; and 
may occur at any time between the fifth or sixth day and the end of the 
sixth week. 

The presence of trichinosis in its acute stage may possibly be confirmed 
by the discovery of parasites in the intestinal discharges, or by the extrac- 
tion by means of a suitable instrument (harpoon) of fragments of striped 
muscular tissue. The under part of the tongue has been specially recom 
mended for exploration. No symptoms attend the presence of the encap- 
suled parasites in the muscles. The diseases with which trichinosis is 
most liable to be confounded are enteric fever, acute tuberculosis, and 
acute rheumatism ; but the distinction between it and them are obvious. 

Treatment We have not, so far as is known, any power to destroy 

trichinae, whether in the intestines or in the substance of the living frame. 
It is of course possible that remedies useful against other intestinal para- 
sites may be useful against these, supposing their presence to be detected 
sufficiently early to justify us in attempting to dislodge them. As a general 
rule, therefore, we can only treat trichinosis on the same principles as we 
treat other affections made up of local inflammatory conditions and general 
fever. But we can also employ prophylactic measures ; and these are, 
fortunately, sufficiently simple. They consist in the avoidance of pork 
which presents the characteristic appearances of the disease, and especially 
of pork which is not well and completely cooked. The mere toasting to 
which ham and bacon are frequently subjected is insufficient to destroy 
the vitality of the trichina. Smoked ham and German sausages are, un- 
less they have been cooked, sources of considerable danger. It is mainly 
in Germany, where pork, raw, smoke-dried, or imperfectly cooked, is a 
common article of diet, that trichinosis is known to occur. 

7. Filaria Sanguinis Hominis. 1 

In the year 1870, Dr. Lewis, of Calcutta, observed that certain minute 
nsematoid worms were constantly present in the urine of persons suffering 
from chyluria ; and two years later he published a short monograph, in 

1 Dr. T. R. Lewis, ' On a haematozoon inhabiting human blood ; its relation to 
chyluria and other diseases' — Calcutta, 1872. ' The Indian Annals of Medical 
Science,' No. xxxiv., July, 1875. And 'The Lancet,' vol. ii., 1877. Also Dr. 
Cobbold, 'The Lancet,' vol. ii., 1877. 



FILAR! A SANGUINIS HOMINIS. 



637 



which, whilst confirming his former statements, he showed that the blood 
of chyluric patients contained the same parasite in more or less abundance. 
Later, namely in 1875, he wrote a paper demonstrating the presence of 
the same animal in the blood and diseased tissues of persons suffering from 
that form of spurious elephantiasis of the scrotum, labia, and leg which 
we have already described under the name of elephantiasis lymphangiec- 
todes. This parasite, to which he gave the name of ' filaria sanguinis 
hominis,' measures on the average -ggVo incn i n diameter and y 1 ^ inch in 
length ; has a rounded anterior extremity, a pointed tail, a definite struc- 
tureless envelope, with slightly granular contents, and no sexual organs. 
The total absence of these organs showed of course that the filarial were 
immature ; and it was important therefore to endeavor to ascertain the 
character and habitat of the parent worms, and the source of infection. 

Filaria? much like the above have been many times observed in the blood 
of the lower animals, more especially dogs, in France, China, and America. 
In such cases both MM. Grube and Delafond and Professor Leidy have 
discovered in the right ventricle of the heart mature worms varying from 
5 to 7 inches in length, with a diameter ranging from J5 to Jg inch ; and 
in the last of Dr. Lewis's papers above referred to he gives an account of 
a series of original investigations with regard to the prevalence of a similar 
parasitic disease in the pariah dogs of India. He shows that a considera- 
ble number of them present in their blood haematozoa w r hich are identical 
in appearance with those found in man ; excepting that they are a little 
smaller, and do not appear to possess the same distinct structureless 
envelope. And on dissection he found : 1st, that along both the oesophagus 
and the thoracic aorta were firm fibrous-looking tumors, varying from the 
size of a pea to that of a walnut, within each one of which were from one 
to six worms of a pinkish tinge — the males varying between 1 and 2 inches 
in length, and between gL an d ^ inch in diameter, the females measuring 
from 2 to 3^ inches long, and from ^ to ^ inch thick ; and 2d, that also 
studding the aorta were nodules, from the size of millet seed to that of a 
pea, containing immature but growing worms from jL inch in length up- 
wards, and also, more or less abundant, scar-like depressions, due either 
to the death of the parasite or to its migration and consequent retrogres- 
sive changes. 

Since the above observations were made, Dr. Bancroft, of Queensland, 
late in 1876 and early in 1877, discovered almost by accident, first in a 
lymphatic abscess in the arm and next in a hydrocele of the cord, mature 
female filarise in length, appearance, and structure not unlike those found 
by Dr. Lewis in the pariah dog, but apparently a good deal thinner. A 
little later (August, 1877) Dr. Lewis found in dissecting a ' naevoid' scrotal 
tumor removed from a patient whose blood contained filarial two mature 
specimens of the worm. With these were found ova, thin-walled, oval in 
form, and measuring from j-$q-$ to mcn m tne l° n © diameter. In 

this as well as in former dissections numerous embryos were found in the 
diseased tissues. He has also found them in great abundance in the renal 
arteries and veins and in the substance of the kidneys. 

Whether the filarial discovered severally in pariah dogs, Indians, and 
Australians, are identical, must at present be regarded as open to doubt. 
At any rate, while no pathognomonic symptoms attend their presence in 
the dog, and it is uncertain as regards the Australian filaria whether its 
immature representatives inhabit the blood ; it is manifest that in India 
not only has the mature w r orm been found in the tissues, but the asexual 



638 



DISEASES OF THE DIGESTIVE ORGANS. 



J 



embryos infest the blood, and characteristic consequences — mainly chyluria, 
and a spurious form of elephantiasis usually implicating the scrotum, labia, 
or lower extremities — are apt to ensue. 

The above facts render it at any rate probable that the filaria sanguinis 
hominis, having found its way (most likely by the alimentary canal) into 
the interior of the organism, takes up its abode therein, and there breeding 
gives origin to the embryos which presently infest the blood. So long as 
the embryos remain in this fluid they undergo no further development ; 
but whether the long duration of the disease is due to the longevity of 
these animalcules, or to the fact that successive families are born either 
from the original parents, or from embryos, which migrating from the 
blood-stream have undergone sexual development, is a question which 
cannot yet be solved. 

As regards the consequences of the presence of filarire, it is important 
to remark that in every case of chyluria and spurious elephantiasis which 
has come under his observation in India since his attention was first 
directed to the subject, Dr. Lewis has found filarise in the blood, veins, 
and discharges from the hypertrophic tissues, often in great abundance, 
but sometimes in such small numbers that they have only been discovered 
after prolonged and careful examination. There are many reasons for be- 
lieving that chyluria and lymphangiectodes originating in this country are 
independent of parasitic disease ; but the subject has not yet been investi- 
gated with sufficient completeness to justify us in asserting that it is so. 
We shall revert to this subject when we come to speak of chyluria. 



XIII. DEGENERATIVE AFFECTIONS OF THE STOMACH 

AND BOWELS. 

Degenerative changes of the mucous membrane play, no doubt, an im- 
portant part in the various chronic disturbances of the stomach and bowels, 
to which the terms dyspepsia, diarrhoea, and the like are usually applied. 
They follow upon chronic inflammation and other persistent lesions of the 
alimentary mucous membrane, and occasionally depend on the presence of 
certain forms of cachexias. They comprise mainly : fatty degeneration 
and wasting of the glands, associated either with general atrophy of the 
mucous membrane or with increased development of fibroid tissue ; and 
lardaceous change. Lardaceous degeneration affects the small intestine 
much more frequently than the stomach or the larger bowel, and probably 
never occurs except in association with advanced lardaceous disease of the 
liver, spleen, or kidneys. The villi chiefly suffer. 

The symptoms referable to the different kinds of degeneration do not at 
present admit of identification. 



XIV. OBSTRUCTION OF THE STOMACH. 

Causation and morbid anatomy Many of the morbid conditions 

which have already been described involve more or less serious impedi- 
ment to the due performance of the mechanical functions of the stomach, 
and consequently to the due transmission of its contents onwards; and 



OBSTRUCTION OF THE STOMACH. 



639 



indeed the symptoms arising from obstruction form an important part of 
their clinical history. 

Obstruction occurs chiefly at the pyloric and cardiac orifices; it may, 
however, arise in some intermediate part. It may be due to mere fibroid 
thickening or cirrhosis ; to malignant disease ; to the cicatrization of large 
ulcers ; to the pressure of external tumors ; to accumulation of hair, cocoa- 
nut fibres, or other solid matters which have from time to time been swal- 
lowed ; to paralysis or spasm. 

The consequences of obstruction at the cardiac orifice have already been 
considered under the head of oesophageal disease ; they are dilatation and 
hypertrophy of the oesophagus, and contraction and atrophy of the stomach. 
In pyloric obstruction the food which is received into the stomach tends 
to accumulate within it, and thus to involve its dilatation and hypertrophy. 
The dilatation under such circumstances is sometimes enormous. If the 
impediment occupy some intermediate position, its influence over the form 
and functions of the stomach will, according to circumstances, approximate 
either to that of cardiac or to that of pyloric obstruction. In some cases 
habitual starvation causes more or less permanent general contraction of 
the stomach ; in some cases habitual over-eating or accidental and ill- 
understood conditions involve extreme dilatation of the organ ; and both 
of these states are apt to be attended with many of the phenomena of 
pyloric stricture. 

Symptoms and progress The symptoms of cardiac obstruction are, 

mainly, ability to perform the act of deglutition, and in rapid succession 
to this act more or less uneasiness, referable to the situation of the cardiac 
orifice, and the rejection of the matters swallowed by a process which 
generally has more resemblance to eructation than to vomiting. The 
patient probably has a good appetite, but cannot gratify it, and suffers 
from all the usual symptoms of starvation. In most cases the obstruction 
is partial only, and more or less food finds its way into the stomach. In 
some the retention of food in the dilated oesophagus lasts for a considerable 
time, and the retained matters prior to their rejection undergo putrefaction 
or fermentation, and become mixed with mucus secreted from the surface 
of the tube. The epigastric region shrinks, owing to the necessary con- 
traction of the starved stomach. 

The symptoms referable to obstructive disease of the pylorus are, in 
many important respects, different from the above. The patient can swal- 
low with ease, and anything that is swallowed finds its way without diffi- 
culty into the stomach ; whence (according to the degree of impediment 
present) it is in part transmitted more or less slowly onwards, in part, 
after awhile (it may be half an hour, an hour, several hours, occasionally 
even several days), and after having caused more or less gastric uneasiness, 
rejected by vomiting. The characters of the vomited matters depend 
largely upon the length of time they have been retained. If they be dis- 
charged shortly after ingestion they consist mainly of partially digested 
food mingled with the normal secretions of the stomach ; if after along in- 
! terval they have generally undergone putrefactive or fermentative changes, 
I are more or less fetid, abnormally acid, and probably contain sarcinae or 
| the yeast-fungus, or both. Their quantity varies considerably, and some- 
i times amounts to several pints. The appetite is more likely to suffer in 
j pyloric than in cardiac obstruction, but is not unfrequently retained. The 
dilatation of stomach which attends this affection reveals itself locally by 
| protrusion of those parts of the abdominal surface with which the organ 



640 



DISEASES OF THE DIGESTIVE ORGANS. 



lies in contact, and probably by displacement of the diaphragm upwards. 
If it be moderate it causes fulness of the epigastric region only ; if it be 
considerable, the body of the organ descends, forming a loop between 
the pyloric and cardiac orifices, and the chief distension then probably 
occupies the umbilical and hypochondriac regions — the epigastrium pre- j 
senting a comparative depression. In some cases the dilated stomach 
occnpies nearly the whole of the anterior part of the abdomen. That the 
distension is due to the stomach is shown : partly by its situation ; partly 
(if it be considerable) by its looped form ; partly by observing the peri- 
staltic movements, which are generally easy of recognition and admit of 
being readily excited ; and partly by the evidences which palpation and 
percussion give of a large cavity containing air and fluid. 

The symptoms due to general contraction of the stomach are especially : 
inability to take food, excepting in small quantities ; irritability of the 
organ ; and tendency to vomit shortly after the ingestion of food. Simple 
dilatation of the stomach differs little, if at all, in its symptoms from in- 
complete pyloric obstruction. 

In all of the above cases, starvation, emaciation, asthenia, and the 
phenomena which attend these conditions supervene with more or less 
rapidity; further various complications are apt to arise in their course and 
to prove fatal, among which may be mentioned gastritis and peritonitis. 

Treatment — The treatment of obstruction must vary somewhat in dif- 
ferent cases, in dependence partly on the side of obstruction, partly on its 
cause. If it be at the cardiac orifice, the careful passage of bougies may 
serve to maintain an available passage ; and, failing this, the question of 
making an opening into the stomach at the epigastrium, and of feed- 
ing the patient through this opening, may be entertained. If it be at the 
pyloric orifice, or if the case be one of simple dilatation, it may become 
necessary under circumstances to empty the distended organ by means of 
the stomach pump, or to let off some of the gaseous accumulation by acu- 
puncture through the abdominal walls. In all cases it is important to give 
food in small quantities at a time, and in the fluid or semifluid condition, 
in which form it most readily passes through a narrowed or strictured ori- 
fice. In cases of pyloric disease or passive dilatation, it is further import- 
ant : that the stomach be not overburdened with food, and hence that this 
be administered in a concentrated form ; that putrefaction and fermentation 
be obviated by the use of appropriate remedies, such as creasote and the 
hyposulphites ; and that tendency to vomit and gastric uneasiness be met 
by the measures elsewhere recommended for these purposes. Lastly, it is 
often necessary to feed the patient per rectum. 



XV. OBSTRUCTON OF THE BOWELS. 

The affections which are here to be treated of present many features in 
common with enteritis, and their description is not infrequently included 1 
in the description of that disease. Enteritis does indeed occur at some 
period or other in the course of most of them ; but their special claim to 
form a group apart consists in the fact of the existence of all of them of 
some mechanical impediment to the transmission of the contents of the 
bowels, in connection with which enteritis is apt to supervene. They are : 
stricture, compression and traction, twisting, internal strangulation, iinpac- 



OBSTRUCTION OF THE BOWELS. 



641 



tion of foreign bodies, and intussusception. It will be convenient to pre- 
face our observations under these heads with some remarks upon their 
common factor, constipation. 

A. Constipation. 

Causation, morbid anatomy, and symptoms — It may doubtless be ac- 
cepted as a general rule that persons enjoying robust health, and undis- 
turbed in the due performance of their various functions, have an alvine 
evacuation at least once daily. Yet many, who at any rate seem equally 
healthy, have their bowels habitually relieved every two or three days 
only, or even but once a week or fortnight. Cases are not altogether 
rare in which some degree of good health has been maintained for many 
years, although fecal evacuations have during that time occurred only at 
intervals of six weeks or two months. Cases, indeed, are on record in 
which the interval between successive evacuations has been extended to a 
period of three months. In most cases, however, retention beyond the 
usual period is apt to produce, not only local uneasiness, such as fulness, 
heat, tendency to piles, and flatulence, but also some degree of general 
disturbance indicated by headache, foul breath, loss of appetite and dys- 
peptic symptoms, and not unfrequently ends with the occurrence of more 
or less tenesmus and even slight dysenteric diarrhoea. Habitual constipa- 
tion is usually attended with chronic discomforts of the same kind ; but it 
leads also to more or less permanent hypertrophy and dilatation of the 
rectum — conditions which render this tube less efficient for the perform- 
ance of its expulsive duties. When constipation is of long duration, not 
only the rectum but the whole of the large intestine may become dilated 
by its contents and hypertrophied, the mucous surface may be fretted into 
ulceration, and perforation may ensue. The dilatation is sometimes so 
great that the colon measures from ten to twelve inches in circumference. 
The chief dilatation occurs in the rectum, sigmoid flexure, and caecum. 
The hypertrophy, under such circumstances, is general, but it is usually 
greatest in the sigmoid flexure and upper part of the rectum, where the 
thickness of the muscular coat may be ^ inch or more. 

Constipation depends on various causes. It sometimes arises tempora- 
rily from change of diet, scene, or habits, among which may be included 
anything interfering with the regular performance of defecation ; it is 
common in many diseases ; and its occurs in a chronic form in chlorotic 
or dyspeptic girls and young women, and in persons of sedentary habits 
or sluggish constitution. Among local conditions which may be supposed 
to operate in a greater or less degree in the above cases are : first, modifi- 
cations in the character of the feces, such as we see in diabetes, where 
they become preternaturally dry and proportionately diminished in bulk; 
second, sluggishness or debility on the part of the rectum itself ; and r 
third, affections at or in the neighborhood of the anus, rendering defeca- 
tion painful. 

B. Stricture. 

Causation and morbid anatomy By this term is meant a circumscribed 

diminution of the calibre of the bowel. Stricture is sometimes due to 
spasm ; but although spasm undoubtedly forms a very important element 
in many cases of intestinal obstruction, it is rare as an independent affec- 
41 



642 



DISEASES OF THE DIGESTIVE ORGANS. 



tion, and in this form is practically limited to the rectum and anus. In- 
deed, spasmodic obstruction, even in these situations, is probably always 
secondary to ulceration, excoriation, or morbid sensitiveness of the mucous 
membrane. Stricture, in the vast majority of cases, is the consequence 
of some organic change — cicatrization after ulcer, cirrhosis, or some adven- 
titious growth (malignant or other) occupying the intestinal walls. It 
rarely follows ulceration unless this be of large extent, or encircle the 
bowel. It seldom, if ever, ensues on the cicatrization of typhoid ulcers, 
and not very often on the healing of tubercular ulcers. It is a much more 
common consequence of dysenteric or syphilitic ulceration, and of the 
separation of a portion of bowel in intussusception. But most frequently 
the ulcer to which it is traceable has, so far as we know, no specific or 
ascertainable origin. Cicatricial stricture may form a mere ring or occupy 
the bowel for several inches of its length. The surface is sometimes com- 
pletely cicatrized ; sometimes presents still unhealed spots of ulceration, 
with fungous excrescences or granulations ; and is often separated from 
the subjacent muscular coat by a more or less abundant formation of dense 
fibroid tissue. Stricture again, especially in the lower part of the rectum, 
is sometimes connected with the progress of chronic inflammatory changes 
or the overgrowth of fibroid tissue, not only in the walls of the rectum, 
but in the surrounding connective tissue of the pelvis. But by far its 
most frequent cause is the development of carcinoma in the substance of 
the intestinal walls. When carcinoma causes stricture or serious obstruc- 
tion, it is, for the most part, a primary growth at the seat of stricture, 
and, like simple ulcer, sometimes forms a mere ring round the gut, some- 
times involves a comparatively large area. Congenital stricture or occlu- 
sion of the bowel is mainly an affection of the anus or rectum, and falls 
therefore especially under the cognizance of the surgeon. It has, how- 
ever, been occasionally met with in the duodenum, in the neighborhood of 
the orifice of the common bile-duct. 

The presence of a stricture always leads, in a greater or less degree, to 
certain results. These are : first, undue accumulation of feces in the 
bowel above, with proportionate dilatation of its tube; second, hypertrophy 
of the muscular walls of the dilated bowel ; and, third, diminution in 
calibre, and even atrophy, of the bowel below. It is an interesting fact 
that, in stricture of the colon, the greatest degree of dilatation is often 
found, not in the portion of bowel immediately above the stricture, but in 
the caecum. The tighter or longer the stricture, the more marked, other 
things being equal, will be the several consequences just named ; and the 
more danger will there be of the supervention of permanent obstruction. 
Yet it is remarkable, that tight and long strictures are often found after 
death in cases in which, during life, there has been no suspicion of their 
presence — a statement more particularly true of stricture of the small in- 
testine, in which part the contents are, as a rule, semi-fluid and easy of 
propulsion. The lodgment of feces above a stricture is very apt not only 
to prevent the complete healing of the ulcer to which originally the stric- 
ture may have been due, but to cause erosion and ulceration in the dilated 
bowel above, and ultimately perforation. 

Stricture may arise anywhere in the bowel, but is met with in different 
parts with different degrees of frequency. Its occurrence as a fatal dis- 
ease in the small intestine is rare. It is mainly indeed a disease of the 
larger bowel. According to Dr. Brinton, out of 100 fatal cases of stric- 
ture of large intestine, 4 occur in the caecum, 10 in the ascending colon, 



OBSTRUCTION OF THE BOWELS. 



643 



11 in the transverse colon, 14 in the descending colon, 30 in the sigmoid 
flexure, and 30 in the rectum. It is more frequent in men than in women ; 
and the average age at which it proves fatal is a little over forty-four. 

Symptoms and progress. — The symptoms due to stricture of the small 
intestine are rarely sufficiently definite to justify us in diagnosing its 
presence. They probably comprise nothing beyond occasional colicky 
pains, nausea, and sickness. Even in the case of the large intestine they 
may be for a long time vague and inconclusive, and even misleading. The 
patient perhaps suffers only from occasional attacks of colicky pain, asso- 
ciated it may be with more or less constipation ; but not unfrequently, 
during the earlier period, diarrhoea is a prominent symptom. If the stric- 
ture be in the lower part of the rectum, solid motions generally soon as- 
sume a narrow tape-like or pipe-like form. 

The symptoms of absolute obstruction occasionally come on quite sud- 
denly, but are more frequently preceded by more or less long-continued 
tendency to constipation. It sometimes also happens that the patient, 
previous to his final attack, has experienced one or more similar attacks, 
which have yielded to treatment. The symptoms of impassable stricture 
are : insuperable constipation ; painful peristalsis, coming on periodically, 
and often rendering itself audible by borborygmi, and visible through the 
abdominal walls; abdominal distension and uneasiness, followed by nausea, 
vomiting, and hiccough ; and death at last from simple asthenia. The 
vomited matters become after a while stercoraceous. Febrile symptoms 
and abdominal tenderness may be absent from first to last; but sometimes 
inflammation supervenes, or perforation takes place, and then enteritic or 
peritonitic symptoms become superadded. When the case is free from 
these or other complications, its progress is essentially chronic, and the 
patient, if not improperly treated, may live for a considerable time, occa- 
sionally for several weeks. 

In determining the seat of stricture, it is well to recollect that at least 
three-quarters of the structures of the large intestine are situated to the 
left of the mesial plane of the body. We need not, however, rest content 
with a simple calculation of chances. It is natural to believe that the 
distension of the bowel above the stricture, and its collapse below, should 
reveal themselves to manual, if not to ocular examination ; and in many 
cases undoubtedly the form and position of a struggling, or even of a qui- 
escent, length of distended bowel may be thus readily identified. It must 
not be forgotten, however, that thickness or rigidity of the abdominal 
walls, tenderness, the presence of tumors, and the altered positions, which 
greatly distended tracts of bowel are apt to assume, often prevent the 
easy recognition of even extreme differences of intestinal dilatation and 
fulness. Dr. Brinton maintains that the amount of fluid which may with 
care be injected per anum is a very valuable guide in estimating, so far as 
the large intestine is concerned, the seat of stricture. This method of 
investigation is, however, scarcely trustworthy, unless the stricture be at 
a comparatively small distance from the anus. But when in this latter 
situation, its presence may often be ascertained by the introduction of the 
finger, or even of the entire hand ; and if it be beyound the reach of actual 
touch, yet in the rectum, the careful introduction of a bougie may possibly 
reveal its position. 



644 



DISEASES OF THE DIGESTIVE ORGANS. 



C. Compression and Traction. 

Causation and morbid anatomy Under these terms we include those 

cases in which the bowel is obstructed either by pressure exerted on it 
from without, or by being dragged out of its normal position by adhesions, 
without being at the same time strangulated. 

Here also may be placed those cases in which the rectum is obstructed 
and defecation rendered painful or difficult by the pressure of a displaced 
or enlarged uterus, or of a uterine or ovarian tumor. Any abdominal 
tumor may, conceivably, have a like effect on some part or other of the 
alimentary canal ; and even the effused blood from a ruptured aneurism 
may surround and compress the duodenum or some part of the colon. But 
the cases here more particularly referred to are those in which obstruction 
is due to the embarrassment of a greater or less length of bowel, caused 
by the presence on its outer surface of lymph or false membrane, which 
binds it more or less firmly to surrounding parts, and sometimes constricts 
it, sometimes leads to the formation of sharp angular bends. In some of 
these cases the bowel has been incarcerated in a hernia, and portions of it 
have become invested in adhesions which attach it to the neck, or some 
other part of the sac, or to the omentum ; in others, the transverse colon 
or sigmoid flexure, or some other tract of bowel, is hooked down, as it 
w r ere, by bands of lymph to the uterus, ovary, or some other structure 
within the pelvis ; in others, again, several contiguous coils of small intes- 
tine are tightly bound together, forming a kind of tangled mass. Fatal 
cases ahvays furnish distinct evidence, in the contraction and emptiness 
of the bowel below, and in the fulness, dilatation, and hypertrophy of the 
bowel above, of more or less complete obstruction. But the part in which 
actual obstruction has taken place, though contracted and more or less 
empty, frequently admit.s with ease of the passage of the finger, or even 
of some larger body. The immediate cause of obstruction, indeed, is 
rarely a simple tight constriction. These lesions are of far more frequent 
occurrence in the small intestine than in the large, and, as Dr. Fagge 
points out, may, from the clinical point of view, be regarded as the stric- 
tures of the smaller bowel. 

Symptoms and progress — The symptoms of these affections are almost, 
if not quite, identical with those of stricture. It is impossible, indeed, to 
make any absolute clinical distinction between them. Obstruction of the 
small intestine, however, is as a rule more early followed by vomiting than 
obstruction of the large intestine ; and it may occasionally be possible, by 
careful examination of the surface of the abdomen, to ascertain whether 
abnormal distension is due entirely to dilatation of the smaller bowel, or 
mainly to distension of the colon. 

D. Torsion or Twisting. 1 

Causation and morbid anatomy Cases are occasionally met with in 

which after death a loop of bowel is found to be twisted, enormously 
dilated and congested, and full of fetid pitchy stuff*, consisting partly of 
fecal matter, partly of the bloody secretion of the affected mucous mem- 
brane. We were formerly inclined to regard the twisting of the bowel in 
these cases as a mere unimportant consequence of localized enteritis. We 



1 [This condition is generally known as volvulus.] 



OBSTRUCTION OF THE BOWELS. 



645 



are compelled, however, to retract this opinion, and to adopt the more 
commonly received interpretation of these conditions : namely, that the 
twist is the primary lesion to which the obstruction and enteritis are 
secondary. The portions of bowel which are most liable to torsion are the 
caecum and sigmoid flexure. The causes of torsion are obscure ; but, at 
any rate, the accident appears to arise suddenly : the affected loop becomes 
twisted, once or even more than that, upon its axis, is at once rendered 
more or less impervious, and what is still more important the trunk- 
vessels which supply it, more especially the veins, by being twisted on 
their axis, also get occluded, and consequently congestion, inflammation, 
gangrene, and paralysis of the bowel ensue. When the twist is of the sig- 
moid flexure the loop of bowel sometimes undergoes such enormous disten- 
sion that it may measure a yard in length, and three or four inches in 
diameter, and may occupy the whole of the front of the abdomen. The 
mucous membrane and submucous tissue become thickened and black with 
congestion and extravasated blood ; and the peritoneal aspect acquires a 
slaty hue, and gets studded with patches and streaks of congestion and 
inflammatory exudation. The contents are such as have been above 
described. The bowel below the lesion is usually contracted and empty, 
while that above it is for the most part more or less dilated, and may pre- 
sent patches of congestion and contain matters which have regurgitated 
from the diseased bowel. 

Symptoms and progress — This affection is sudden in its onset, and in 
most cases rapidly fatal — the patient sometimes dying in the course of a 
day or two, rarely surviving for a week. The symptoms are in the main 
those of strangulated hernia. The patient generally suffers at first from 
severe abdominal pain, attended with constipation, vomiting, and rapid 
flatulent distension of the belly. And although febrile phenomena may 
occur, he very rapidly falls into a condition of collapse, with failing tem- 
perature, clammy perspiration, feeble and irregular pulse, sighing respira- 
tion, great muscular debility and restlessness, and withal more or less 
drowsiness. Generally the urine is scanty or suppressed ; the bowels com- 
pletely obstructed ; and the patient sensible to the last. 

It is remarkable that in these cases vomiting; and hiccough are often 
absent in a greater or less degree, at any rate are not prominent symp- 
toms ; and that notwithstanding the enormous distension of the abdomen 
there is frequently little or no absolute pain, excepting early in the 
disease, and little or no tenderness. Indeed, the patient often, as in 
colic, is relieved by pressure or friction. It is important to add that when 
the torsion involves the sigmoid flexure, the long tube may easily be 
introduced into the diseased bowel ; and that the nature of the case may 
possibly be diagnosed partly by this fact, partly by withdrawing some of 
the contents. 

E. Internal Strangulation. 

Causation and morbid anatomy — This arises from similar causes to 
those Avhich produce ordinary strangulated hernia, namely, constriction or 
nipping of a portion of bowel by the edges of some natural or artificial 
orifice through which it protrudes, with consequent arrest of the circula- 
tion of blood through it, and impediment to the passage of fecal matters 
along it. Such orifices are the foramen of Winslow, congenital or acquired 
perforations in the mesentery, meso-colon, great omentum, or other peri- 



646 



DISEASES OF THE DIGESTIVE ORGANS. 



toneal duplicatures, or apertures formed with the aid of neighboring parts 
by bands of fibroid tissue extending from one point of the peritoneal sur- 
face to the other. 

Hernial protrusion through the foramen of TVinslow must be exceedingly 
rare. Perforation of the various peritoneal duplicatures, with passage of 
bowel through the perforation, is much more common, and oft^n the result 
of laceration from violence. This accident is most frequent in connection 
with the mesentery ; but it occurs also in connection with the great 
omentum, the meso-colon, the fold belonging to the vermiform appendix, 
the suspensory ligament of the liver, and the broad ligament of the uterus. 
There is no part of the peritoneal surface to which bands capable of pro- 
ducing strangulation may not be attached ; but there are certain structures 
and certain conditions of parts with which they are specially apt to be 
connected. Thus the vermiform appendix often adheres to neighboring 
structures, such as the mesentery, small intestine, colon, and ovary, form- 
ing a kind of loop ; diverticula of the ileum become attached, usually by 
the apex, to the mesentery or some other adjoining part, or are prolonged 
to the umbilicus by a cord — a remnant of foetal life. Again, such bands 
are often connected with the mesentery, the parts concerned in old rup- 
tures, or the pelvic organs — more particularly the uterus, Fallopian tubes, 
and ovaries. It may further be noted that strangulation occasionally 
results from the slipping of a loop of intestine under the lower edge of the 
unusually elongated mesentery of a portion of bowel hanging low into the 
pelvis, or under the pedicle of an ovarian or uterine tumor. Finally, there 
are rare cases of internal strangulation in which the bowel protrudes into 
a lacerated bladder, uterus, vagina, or bowel, or through an acquired or 
congenital communication between the peritoneum on the one hand, and 
the pericardium or one of the pleura? on the other. 

The small intestine is much more frequently strangulated than the large ; 
and of the large intestine the parts most liable to this accident are those 
which are most freely movable, especially the sigmoid flexure and the 
caecum. Internal strangulation occurs at any age, but generally above 
thirty. It seems, however, that strangulation from bands connected with 
the vermiform appendix and diverticula are most common at a compara- 
tively early age. 

The symptoms of internal strangulation are identical with those of or- 
dinary strangulated hernia, and so like those which have already been 
described as the symptoms of torsion and the severer forms of enteritis, 
that there is no need to give any special account of them. 

F. Impaction of Foreign Bodies. 

Causation and morbid anatomy. — The ordinary intestinal contents, no 
matter how indigestible, unwholesome, or imperfectly comminuted the in- 
gesta from which they are derived may be, very rarely cause by their 
accumulation permanent intestinal obstruction ; yet it is doubtless the fact 
that undigested masses of food do sometimes in their passage along the 
small intestine move with difficulty or become temporarily impacted and 
so produce pain and sickness and even symptoms of obstruction. Hard 
foreign bodies of comparatively small size — coins, bits of bone, teeth, 
marbles, plum-stones, and the like — generally traverse the intestine with- 
out causing inconvenience ; and occasionally sharp bodies, such as pins, 
prove equally innocuous. They are all, however, a source of danger, 



OBSTRUCTION OF THE BOWELS. 



647 



especially in the presence of strictures, above which they are apt to he- 
come lodged ; or from the fact that they may slip into diverticula or the 
vermiform appendix, or (if they be hard and pointed) may perforate the 
intestinal wall, and cause, according to the seat of perforation, fatal peri- 
tonitis, circumscribed abscess, or fistula. Further, an accumulation of 
such bodiesf as for example a large number of cherry-stones, may become 
welded into a mass sufficiently bulky to obstruct fatally a perfectly healthy 
bowel. Insoluble matters in the form of powders or fibres, when habitually 
swallowed even in small quantities, often concrete into hard masses. These 
sometimes are round or oval, and may then be termed intestinal calculi, 
sometimes form hollow casts of the portion of the gut in which they lie. 
The former are probably always found in the large intestine ; the latter 
rarely, if ever, occupy any other portion than the rectum. Among the 
substances here referred to are peroxide of iron, carbonate of magnesia, 
imperfectly cooked starch, and oat-hairs derived from articles of food made 
from oats. Among cases of exceptional rarity must be named those of 
persons who have been in the habit of swallowing knives, pins, string, 
hair, or cocoa-nut fibres. These things are generally found accumulated 
either in the stomach or in the upper part of the small intestine, and when 
fibrous usually become felted and form masses which take the shape of the 
cavities in which they lie. 

But the usual cause of fatal impaction, and that with which we now 
have more especially to do, is the escape of biliary concretions from the 
gall-bladder into the small intestine. The concretions here referred to are 
single stones or masses of coherent stones of considerable bulk, varying at 
a rough estimate from three to four inches in circumference, and from one 
inch to two, three or even four in length. It is obvious that concretions 
of this magnitude can scarcely escape from the gall-bladder per vias na- 
turales ; and indeed there is little doubt that their discharge is in all cases 
effected through an ulcerated opening between the gall-bladder and duo- 
denum. When such a body has got into the duodenum it is carried on 
with the other contents of the bowel by the ordinary peristaltic movements. 
But its mere bulk prevents it from moving rapidly; besides which it pro- 
vokes by its shape, size, and hardness some irritation if not inflammation 
in the mucous surface over which it passes, and more or less spasmodic 
contraction of the muscular walls. It hence continues its progress fitfully 
onwards, until finally it becomes permanently arrested, sometimes in the 
jejunum, but more commonly in the ileum, especially in its narrowest 
part, just above the ileo-cascal valve. Then all the effects of complete 
obstruction, conjoined with those of enteritis, supervene : the bowel below 
becomes empty, that above distended and generally more or less inflamed ; 
while at the seat of obstruction and in its immediate neighborhood the 
inflammation becomes intense, speedily extends to the peritoneal surface, 
and not rarely ends in gangrene and perforation. Gall-stones seldom if 
ever lodge in any part of the large intestine ; and when large ones are < 
found there they have probably gained an entrance directly by ulceration 
between the gall-bladder and transverse colon. Gall-stones are usually a 
product of the later periods of life; and hence obstruction from them can 
scarcely be looked for excepting in advanced age. It occurs, indeed, 
rarely before the age of fifty, and much more frequently in women than in 
men. 

Symptoms and progress The symptoms due to the impaction of gall- 
stones are as nearly as possible identical with those of internal strangula- 



648 



DISEASES OF THE DIGESTIVE ORGANS. 



tion or enteritis. These cases, however, are amongst the most violent in 
their symptoms and the most rapid in their course of all cases of intestinal 
obstruction. Dr. Brinton calculates their average duration at five days. 
A clue to the nature of the case may sometimes be furnished by the occur- 
rence of precursory symptoms due to the passage of the calculus along the 
bowel, and by the detection of the hard mass itself in transitu. The age 
and sex of the patient are also suggestive. There is not necessarily or 
even generally in these cases any history of hepatic colic or other indica- 
tion of hepatic affection. 

G. Intussusception. 

Causation and morbid anatomy — By this term is meant the descent or 
prolapse of a portion of the bowel into that which immediately succeeds it 
and is continuous with it. As the result of this accident we find the nor- 
mal course of the intestine interrupted by a kind of knot, in which three 
successive lengths of tube lie almost concentrically one within the other — 
the innermost being the portion of bowel which has descended, the outer- 
most the portion into which the descent has occurred, the middle or inter- 
mediate length that which unites the lower extremity of the former with 
the upper extremity of the latter. The last is of course inverted, and has 
its mucous aspect facing outwards and in contact with that of the outermost 
layer. In the descent of the inner two lengths of bowel the mesentery 
belonging to them is necessarily dragged down with them into the pouch 
which they form, and by the traction which it exerts tilts the double tube 
or invaginated portion of bowel so that the lower orifice instead of lying in 
the axis of the containing bowel faces and rests upon some portion of its 
circumference. The several layers generally present more or less trans- 
verse corrugation, and this condition is always most marked in the middle 
tube. The immediate effects of intussusception are : first, more or less 
obstruction to the passage of the intestinal contents ; and, second, more or 
less impediment to the return of blood from the inner two cylinders of in- 
volved bowel, to which the stretched and compressed mesentery belongs. 
Nevertheless the obstacle which an intussusception opposes is often incom- 
plete ; for it is certain that in a good many cases fecal matters pass pretty 
constantly through it. The obstruction to the venous circulation very 
soon renders the mucous and muscular coats of the inner two tubes black 
or nearly so with congestion and effusion of blood ; and the serous surface 
assumes a more or less deep slate color. At the same time these parts 
become much swollen, and sanguinolent serum or blood escapes from the 
mucous membrane into the interval between the opposed surfaces of the 
outer two tubes, into the central canal, and into the bowel below the seat 
of disease. At a somewhat later period coagulable lymph is secreted from 
the opposed serous surfaces of the middle and internal layers, and these 
may consequently become agglutinated in their whole length. In most 
cases an intussusception increases for a time more or less rapidly, owing to 
the active peristaltic movements of the several segments engaged. This 
increase is so effected that that portion of the bowel which formed the 
lowest point of the invaginated mass in the first instance continues to form 
its lowest point to the end of the chapter ; in other words, the middle tube 
of an intussusception increases in length at its upper end only, and at the 
expense of the outer tube. The length of bowel engaged in an intus- 
susception varies widely. Including in one measurement the inner two 



OBSTRUCTION OP THE BOWELS. 



649 



tubes only, it may be said to range usually from two or three inches up to 
three or four feet. Dr. Peacock records' a case in which there were good 
grounds for believing it to have been no less than twelve feet. 

Intussusception may arise at any part of the intestinal canal, but it oc- 
curs in different parts with different degrees of frequency. Jejunal and 
ileal intussusceptions are met with almost exclusively in adults, and form 
collectively about one-third of the total number of fatal cases. These are 
j usually attended with rapid strangulation of the bowel, and run a rapid 
I and for the most part rapidly fatal course. Ileo-csecal invagination occurs 
largely among young children, including babes of a few months old. Ac- 
j cording to Dr. Brinton half the total number of these cases are in children 
under seven years of age. This is the most common form of the disease, 
accounting for more than half the total number of deaths. It commences 
with the descent into the cavity of the caecum of the lips of the ileo-caecal 
orifice, which henceforth form the lower extremity of the invagination. 
As this increases the descending ileo-caecal orifice carries down with it 
more and more of the ileum to form the central tube, and inverts first the 
caecum and then a gradually increasing quantity of the colon to form the 
inverted or middle layer; and, still descending, finally, in some cases, 
reaches the rectum, or even protrudes from the anus. It is in this variety 
that the greatest length of bowel may be engaged ; in it the transverse 
folding of the several layers of intestine is usually well shown, especially 
in the middle tube, which is often also much convoluted and twisted ; and 
in it complete strangulation and complete obstruction to the passage of 
feces are comparatively rare. Intussusception, commencing in the colon, 
is of somewhat unfrequent occurrence ; and still more rare is intussuscep- 
tion of the rectum. The rarest form of all, probably, is that due to the 
descent of the ileum, through the ileo-csecal orifice. 

If the patient survive sufficiently long, various consequences are apt to 
ensue. The inflammation, which by its products unites the opposed serous 
surfaces of the inner two layers, may spread beyond its primary seat, and 
cause general peritonitis. Or after these layers have become united, a 
further descent of bowel may take place into the portion already invagi- 
nated. Or the extremity of the invaginated bowel may fret the wall of 
its containing tube and cause its ulceration and even perforation. By far 
the most interesting and important event is the sloughing and separation 
of the included layers of bowel. This occurs almost exclusively in those 
cases in which the small intestine is alone engaged, and the strangulation 
of the contained bowel is most complete. This, first deeply congested, 
soon becomes gangrenous, and then, after a while, getting detached either 
bit by bit or in mass, gradually works its way downwards, and is expelled. 
The separation of the slough generally leaves the upper extremity of the 
outermost tube firmly united at the neck of the intussusception with the 
lower extremity of the healthy bowel above. But during the process of 
separation the adhesions are apt to get ruptured, and fecal matter to be 
extravasated into the peritoneal cavity. The discharge of the invaginated 
bowel usually occurs between the twentieth and thirtieth day ; but it may 
take place as early as the sixth or seventh clay, or be delayed for a year 
or two. The results of separation seem to be favorable in about half the 
total number of cases. In the remainder death often results sooner or 
later from stricture. 

Symptoms and progress The occurrence of intussusception is attended 

with sudden and severe abdominal pain of a griping or twisting character, 



650 



DISEASES OF THE DIGESTIVE ORGANS. 



usually referred to in the neighborhood of the umbilicus. This generally 
ceases in a short time, but, after an interval, recurs temporarily, and then 
perhaps continues to recur and remit alternately. There is not necessarily 
any abdominal tenderness, and indeed the patient frequently finds relief, as 
in colic, from pressure on the abdominal parietes. Sympathetic vomiting 
may be an early symptom, but in the beginning is often absent. Consti- 
pation generally follows upon the sudden attack of pain. Sometimes, on 
the other hand, there is actual diarrhoea, and generally more or less abun- 
dant discharge of blood furnished by the congested bowel. The symptoms 
which mark the subsequent progress of the case depend partly on the 
situation of the intussusception, partly on the degree of strangulation. 

In ileo-caecal invagination strangulation is rare, and the case tends to be 
protracted. In this event the symptoms are apt. to be ill-defined ; the 
paroxysms of pain are often slight, and recur at distant intervals ; consti- 
pation may exist at the beginning only, or may recur from time to time, 
or may never be distinctly present; and there is generally more or less 
vomiting. As the case progresses, however, the pain often increases in 
severity ; the vomit'ng becomes more or less incessant, and probably ster- 
coraceous ; the alvine evacuations either continue to pass or become re- 
established ; blood and mucus are discharged in variable quantities ; and 
even dysenteric diarrhoea may come on. And then, after a longer or 
shorter period, sometimes two, three, or four months, the patient, who has 
been gradually getting emaciated and feeble, dies of simple exhaustion. 

When the small intestine is the seat of disease, strangulation usually 
takes place at once, and its occurrence adds the symptoms of enteritis to 
those of mere invagination. The case, therefore, speedily assumes a very 
threatening aspect. Febrile symptoms manifest themselves, the abdomen 
becomes tender, incessant vomiting comes on, the bowel gets occluded, but 
at the same time probably blood in some abundance is discharged per 
anum. With such symptoms the patient, as in simple enteritis or internal 
strangulation, may speedily succumb ; but sometimes, at a moment when 
the disease appears still to be progressing unfavorably, the constipated 1 
bowel begins to act, offensive stools, mixed with blood and mucus, begin j 
to be discharged, vomiting diminishes or ceases, febrile phenomena abate, j 
.and, after a longer or shorter time of dysenteric symptoms, a sequestrum j 
is voided in the form of a dark fetid gangrenous mass. 

A further indication of the presence of intussusception is the discovery 
of a tumor. No doubt this cannot always be detected ; but it is most 
likely to be found in cases of ileo-csecal or colic invagination. That the 
tumor is due to intussusception may be gathered : partly from its position ; 
partly from its form ; partly from the fact of its gradual enlargement and 
change of position ; but above all from its hardening and enlarging and 
then subsiding under the influence of peristaltic movements. If the tumor 
descend into the rectum or protrude externally, its nature may of course 
be readily recognized. The distinctions which have been drawn between 
invaginations of the small intestine and those of the large — to wit, that in 
the former case the symptoms are usually more sudden and severe, vomit- 
ing earlier and more persistent, constipation more complete, discharge of 
blood per anum more profuse, inflammation more intense, and death more 
rapid — are no doubt true of most cases, but they are not to be relied upon 
absolutely ; for it occasionally happens that invaginations of the small in- 
testine assume a chronic character, and still more frequently that those of i 
the large take an acute course and even end in the detachment of the 



OBSTRUCTION OF THE BOWELS. 



651 



invaginated portion. The percentage mortality of intussusception is very 
large. It must be observed, however, that in arriving at this conclusion 
we necessarily exclude all those cases in which intussusception is found 
accidentally after death from other diseases, and those (which we believe 
to occur now and then) in which intussusceptions form during life and 
disappear again after the temporary production of symptoms of more or 
less severity. The average duration of cases fatal' from enteritis appears 
to be about five days. 

H. Concluding Remarks in reference to Symptoms. 

Before dismissing the subject of intestinal obstructions it may be con- 
venient to consider some of the more important points upon which our 
discrimination of cases that come before us must depend. 

1. Pain is a more or less general and prominent symptom in all cases of 
obstruction. It is sometimes due to peritonitis, sometimes to colic, some- 
times to both of these causes. It varies in intensity in different cases, 
and may be almost entirely absent. Pain of peritonize quality attends 
those cases of obstruction which are accompanied by enteritis, and is apt 
to subside as tympanites supervenes and the fatal event approaches. 
Colicky pains constitute one of the most characteristic and at the same 
time one of the most distressing symptoms of intestinal obstruction. They 
come on in paroxysms, and are attended with more or less violent peris- 
taltic movements of the bowel above the seat of obstruction, which are 
often distinctly visible through the abdominal parietes, and may even from 
their course and point of apparent cessation furnish a clue to the seat of 
impediment. These pains may be present in a marked degree in all forms 
of obstruction, but are most severe and most constant in the cases of long-' 
est duration — in those, therefore, in which enteritis is either not present 
at all or comes on late. 

2. Vomiting is rarely if ever entirely absent. At first it is merely 
sympathetic. But after a while it is due to mechanical causes. The 
bowels above the seat of the obstruction get distended by their contents, 
which are partly the ingesta, partly the secretions of the mucous surface. 
These, by the combined effects of simple overflow, peristaltic action, and 
pressure from without, regurgitate into the stomach, and then become 
voided, constituting what is called stercoraceous vomit. This may be pea- 
soap-like and fetid from decomposition, but is never derived from the large 
intestine or truly fecal. Vomiting is generally an early symptom in all 
cases of intestinal obstruction, and in those of acute progress may continue 
to the end without cessation. Yet even in some of these it intermits, and 
may be absent for a comparatively long period. In more chronic cases its 
occurrence is extremely variable, but even here it generally becomes more 
or less constant and stercoraceous towards the close of life. Vomiting is 
an earlier, more constant, and more severe symptom, in proportion to the 
nearness of the seat of obstruction to the stomach. In obstruction of the 
large intestine it is usually long delayed, and may never be a prominent 
symptom. 

o. Constipation is of course one of the most characteristic phenomena 
of obstruction ; yet fecal matters will often pass with little difficulty 
through even a tight stricture, especially of the small intestine. Nor must 
it be forgotten that generally at the time at which complete obstruction is 
established, the bowel below contains larger or smaller quantities of feces 



652 



DISEASES OF THE DIGESTIVE ORGANS. 



which may be removed naturally or by injections. Scybala are sometimes 
found post-mortem in the large intestine below a complete obstruction of 
many weeks' standing. Nevertheless, insuperable constipation coming on 
suddenly is a striking feature of internal strangulation and of the lodg- 
ment of gall-stones ; insuperable constipation coming on gradually or with 
premonitory stages, of stricture and compression. In intussusception also 
there is generally sudden constipation of varying duration ; but the inva- 
ginated mass, especially when the large intestine is involved, is rarely quite 
impervious, so that before long, at all events in chronic cases, the trans- 
mission of fecal matters is resumed. In intussusception, moreover, blood 
is apt to be passed at an early period by stool ; and is generally passed in 
abundance when the small intestine is the part affected. 

4. Tumor and shape of belly. — The belly usually becomes before long 
more or less tense and tympanitic in consequence of the accumulation of 
gas in the parts above the seat of obstruction ; and the form of the stomach 
or of certain convolutions of the bowels may sometimes be distinctly 
mapped out. Careful attention to the form of the belly, to the visible 
movements of the organs beneath, and to the sounds elicited by percussion 
will often aid us in determining the seat of disease. Still too much reli- 
ance must not be placed upon these phenomena, for certain lengths of 
bowel become in some cases so enormously distended that they not only 
conceal all the other viscera, but a coil of small intestine may equal in 
diameter a distended colon, and either of them may simulate the stomach. 
The detection of a lump is an indication of capital importance. It may 
be due to the presence of a gall-stone or some other concreted mass lodged 
in the bowel ; it may (in cases of stricture) be a mass of malignant dis- 
ease ; it may be the evidence of intussusception. 

5. The condition of the urine is a matter of interest. In some cases 
of obstruction there is almost total suppression ; in some there is an 
abundant limpid discharge. Dr. Barlow, Avho first observed this differ- 
ence, attributed scantiness of urine to the obstruction being high up in 
the bowel, and to the consequently little available surface left for absorp- 
tion ; plentifulness of urine to the opposite conditions. Dr. Brinton, 
accepting Dr. Barlow's facts, referred the deficiency of urine to the abund- 
ant vomiting which attends the one class of cases, and the copious secretion 
of that fluid to the comparative absence of vomiting which is usual in the 
other class. Mr. W. Sedgwick, however, argues that the diminution or 
suppression of the urinary secretion is related to the suddenness and in- 
tensity of the symptoms, and is due to the influence of the sympathetic 
system. On the whole, there is reason to believe that the diminished 
secretion, which is often only temporary, characterizes mainly those cases 
in which the symptoms are sudden and acute ; and almost necessarily, 
therefore, in larger proportion, cases involving the small intestine than 
cases involving the large. 

6. Duration of life. — Complete obstruction occurring in the rectum or 
colon may not prove fatal for several weeks or even several months. Death 
as a rule supervenes earlier in proportion as the impediment is situated 
near the stomach. When, however, enteritis is associated with obstruc- 
tion, then, wherever the obstruction may be, the progress of the case is 
always rapid, and, dating from the commencement of enteritic symptoms, 
rarely occupies more than a week, often only three or four days. 

7. Statistics According to Dr. Brinton's figures, based on 500 deaths 

from obstruction, it appears that in every 100 cases, 43 are due to intus- 



OBSTRUCTION OF THE BOWELS. 653 

susception, 17 to stricture, 4-8 to impaction of gall-stones, 27*2 to internal 
I strangulation (including, however, all those cases which have been ascribed 
above to compression or traction), and 8 to torsion or twisting. 

I. Treatment. 

1. The treatment of constipation turns, in different cases, upon very 
| different considerations. A temporary attack may be put right by the use 

of a simple purge — a dose of castor oil, a black draught, a colocynth pill, 
or a simple enema. In young babies the mere introduction of the nozzle 

| of the enema tube, or the insertion into the anus of the point of a piece of 
soft paper rolled into the form of a pencil, is often amply efficacious. 
When constipation is of a more permanent character it may often be over- 
come by the mere persistent repetition of daily efforts at some particular 

j time (preferably after breakfast) to evacuate the rectum ; or by the habitual 
use of particular kinds of food, such as brown or bran bread, of a large 
proportion of fresh vegetables or fruit, or of dried fruit, such as plums and 
figs ; or, again, by the daily use of small doses of mild laxatives, such as a 

J few stewed prunes, a teaspoonful of confection of senna or of castor oil, 
taken in the morning, on an empty stomach ; or by the similar employment 
of a combination recommended by Trousseau of one-sixth or one-seventh 
of a grain of podophyllin combined with an equal quantity of extract of 
belladonna. In some of these cases, a course of iron, strychnia, belladonna, 
or atropia in small doses, either alone, or combined with mild aloetic or 
other purgatives which act especially on the lower bowel, is serviceable ; 
as also is the occasional employment of simple or purgative enemata. Gal- 

| vanism applied to the surface of the abdomen, or to that and to the anus, 
is occasionally efficacious. In some cases much more active purgation is 
needed ; and in some it becomes absolutely necessary to dislodge the hard 
fecal accumulation by the finger, spoon, or some such instrument, or by 
the use of repeated enemata, or, better still, by directing a forcible stream 
of warm water, conducted from a height by means of a tube, into the rec- 
tum, and allowing it to play upon the fecal mass for half an hour or so at 
a time, and thus to cause its disintegration, and either effect or facilitate 
its removal. 

2. The treatment of cases of obstructed bowel must be regulated partly 
in accordance with what we know or suspect of the nature of the cause of 
obstruction, partly in accordance with the character of the symptoms 
present. It may be laid down as a general rule, from which it is highly 
unsafe to depart, that, whenever the symptoms of obstruction are asso- 
ciated with those of enteritis — whenever, in fact, there is besides obstruc- 
tion obvious inflammation — the treatment to be adopted is that already 
recommended for cases of enteritis : namely, the local abstraction of blood, 
and application of fomentations, the use of opium in sufficiently large quan- 
tities, the avoidance of purgatives, the administration of food in small 

j portions and in the liquid form, and all those subsidiary measures which 
are elsewhere considered in sufficient detail. This is the form of treatment 

! that is especially applicable to cases of internal strangulation, impaction 

j of foreign bodies, and jejunal or ileal intussusception. 

In those cases, however, in which the symptoms of obstruction come on 

I vaguely and without evidence of association with inflammatory mischief, 
it is generally advisable to commence the treatment with the administra- 
tion, either by the mouth or by the rectum, of moderately powerful pur- 



654 



DISEASES OF THE DIGESTIVE ORGANS. 



gatives, and to persist in this treatment until, by their failure to act, and 
by their causing vomiting, and painful but fruitless peristaltic movements, 
their inefficiency is distinctly shown. It sometimes happens that, after 
drastic purgatives have failed, a large dose of some simple laxative, such 
as castor oil, acts with singular efficacy. In aid of this treatment, hot 
baths, fomentations, ice or electricity to the surface of the belly, and 
voluminous enemata of gruel or water, administered by the long tube, may 
severally be employed. If these measures are without avail, it is gene- 
rally advisable to give the bowels rest, and to relieve pain by the repeated 
use of adequate doses of opium or belladonna ; the persistence in which 
treatment will, by relieving spasm or otherwise promoting the return of 
some length of bowel to a comparatively healthy condition, not unfre- 
quently result, after a shorter or longer time, in an effectual and sufficient 
evacuation. If this treatment fail in its turn, it may be necessary again 
to solicit the action of the bowels by the employment of purgative medi- 
cines, enemata, and the like. Such is the routine that must generally be 
followed in cases of simple obstruction, in which the cause of obstruction 
is obscure ; and in many cases also even when the cause is distinctly 
ascertained. 

When, however, the obstruction depends on the presence of a stricture 
in the rectum or sigmoid flexure, the persistent use of powerful purgatives 
is scarcely judicious ; copious and frequently repeated enemata are then of 
especial value. If the stricture be within reach it may admit of dilatation 
by the bougie. Again, when the obstruction is due to an ileo-caecal or a 
colic intussusception, powerful purgation is likely to do more harm than 
good ; large enemata, however, are occasionally efficacious in causing the 
reduction of the intussuscepted bowel. But the most powerful, and appa- 
rently the most efficacious, form of enema for this purpose appears to be 
the inflation of the large intestine with air. Lastly, when, in cases of 
obstruction, the bowel is working with visible violence and pain ; or we 
have reason to believe that (as in the course of those cases in which the 
invaginated portion of bowel is discharged per anum, and in all cases 
where there is, and has been for some time, much tympanites) the bowel 
is enfeebled and in danger of rupture, purgatives must be religiously 
avoided. 

In the course of many cases of obstruction, the question of relieving 
the patient by surgical means must necessarily arise. The time at which 
an operation should be performed, and the nature of the operation to be 
performed, are of course matters of grave importance. It may be accepted 
as a general rule that when once the desirability of this procedure has been 
recognized, the earlier recourse is had to it the better. Exploratory ope- 
rations with the object of discovering the nature of the impediment, and 
then, if possible, of relieving it, are rarely successful. There are, how- 
ever, some circumstances under which operations are not only justifiable, 
but imperatively demanded. No patient who has either a rupture (even 
if there be no evidence of strangulation in it) or a hernial sac, or any trace 
or hint of any affection of the sort, should be permitted to die with symp- 
toms of obstruction without having the chance afforded him which an ex- 
ploratory operation at the suspected site affords ; nor should we, with the 
object of unfolding the involved bowel, hesitate to perform gastrotomy in 
cases of ileo-csecal intussusception which have resisted other modes of 
treatment. Other operations which are often serviceable in prolonging 
life, and are sometimes curative, consist in opening the bowel and forming 



ASCITES. 



655 



an artificial anus in some convenient spot above the seat of obstruction. 
Such operations are especially applicable when the large intestine is the 
seat of disease. If the obstruction be in the rectum or sigmoid flexure, 
the opening should be made in the left loin into the descending colon ; if 
above these portions of the bowel, then in the right loin and into either 
the caecum or the ascending colon. If the obstruction be in the csecum 
itself, or in the small intestine, Littre's operation is alone available. This 
consists in laying open the peritoneal cavity, and then opening the bowel 
(having first brought the part to be divided to the surface) above the seat 
of stricture. The lips of the wound in the intestine must be attached by 
sutures to those of the incision in the abdominal walls. The enormous 
gaseous distension of the bowel which often takes place in obstruction is a 
cause of great discomfort, and even adds to the patient's risks. It may be 
relieved by puncturing the distended gut through the abdominal parietes 
with a grooved needle or fine trocar and canula. The operation is attended 
with little or no danger. 



XVI. ASCITES. {Abdominal Dropsy.) 

Causation and morbid anatomy. — The above terms are applied to the 
accumulation of serum within the peritoneal cavity. Ascites is an accom- 
paniment or sequela of many different diseases ; but depends immediately 
on some condition which modifies the action of the capillary vessels or 
lymphatics of the peritoneal membrane. This condition may be either 
some morbid process going on in the peritoneal tissue ; some impediment 
to the flow of blood through the portal vessels ; or some disease influencing 
the systemic circulation generally. 

1. More or less effusion of serum attends ordinary cases of acute peri- 
tonitis. But such accumulations are rarely abundant, and generally soon 
disappear. Chronic peritonitis, on the other hand, is a common cause of 
persistent and progressive ascites, and especially perhaps those forms of 
chronic peritonitis which occur in women in connection with inflammatory 
conditions of the pelvic organs and the growth of ovarian cysts. In some 
of the latter cases the dropsy is due to the rupture of cysts and the dis- 
charge of their contents into the peritoneal cavity. Tuberculosis and 
malignant disease of the peritoneum are other frequent causes of ascites. 

2. Impediment to the flow of blood through the portal system, and con- 
sequent ascites, may be referable to direct compression of the portal trunk 
by cancerous, aneurismal, or hydatid tumors arising external to the liver, 
or by tumors of various kinds originating in its substance, and especially 
by cancerous or fibroid growths occupying the lesser omentum and extend- 
ing thence into the liver along the capsule of Glisson. Most commonly, 
however, they are caused by general diseases of the liver, involving the 
hepatic capillaries and the minute veins which open into and emerge from 
them. Of these cirrhosis is the most frequent and important. But the 
simple induration and congestion which constitute the i nutmeg liver' may 
have the same effect, as also possibly may lardaceous degeneration. The 
compression of the liver by a fibroid capsule of inflammatory origin may 
act in the same way as cirrhosis. 

3. Among the diseases by which dropsical effusion into the belly, as a 



656 



DISEASES OF THE DIGESTIVE ORGANS. 



part of general dropsy, may be caused, are heart-disease, chronic affections 
of the lungs, and certain forms of renal disease ; to which may probably 
be added various cachexias and simple ansemia. In many of these cases 
the ascitic accumulation is proportionate only to the dropsy of other parts. 
In some cases, however, it becomes excessive, while the dropsy elsewhere 
undergoes but little increase. When this is the case there is generally 
some local complication (coming under the first or second group of causes 
which have been considered) to which this disproportion is attributable. 

The amount of fluid present in ascites may vary between a few pints 
and four or five gallons. Its quality also may vary. It is usually 
slightly viscid, transparent, of a yellowish or greenish tinge, alkaline, and 
containing both albumen and fibrinogen, and often fibrinous clots. It is 
sometimes very viscid (especially in cases of ovarian tumors or colloid 
cancer), sometimes opaline from the presence of inflammatory or other 
products, or turbid and discolored with blood in a more or less altered 
form. 

Symptoms and progress — The accumulation of fluid in the abdominal 
cavity causes its gradual distension, and sooner or later obstructs the 
intra-abdominal veins, especially those connected with the lower extremi- 
ties, impedes the movements of the diaphragm, and interferes more or less 
injuriously with the healthy action of the abdominal viscera. It modifies 
also the patient's gait, making him walk like a pregnant woman, with his 
legs wide apart and his head and shoulders thrown back. The ascitic 
abdomen is large, uniformly rounded, with a tendency to spread or bulge 
in the flanks as the patient lies on his back, tense, and more or less smooth 
and shining, and often presents distended superficial veins and that linear 
atrophy of the skin so common in pregnancy. The stomach and intestines 
tend of course to float on the surface of the fluid; and hence generally the 
highest part of the abdomen is resonant, the more dependent parts dull — 
the line of demarcation between them being for the most part well defined 
and horizontal, but varying with the varying positions which the patient 
assumes. The liver, which is of higher specific gravity than dropsical 
fluid, often retreats distinctly from the anterior surface of the abdomen and 
from the diaphragm, a stratum of fluid with sometimes a loop of bowel 
occupying the interval. The presence of fluid is further indicated by the 
peculiar thrill which is experienced by the hand laid flat on the abdomen 
when a ripple or wave is produced in the ascitic fluid by a slight tap or 
fillip applied to some other part of the abdominal surface. 

These signs are not always all present, or at least easy to recognize; 
and not unfrequently tumors and other conditions simulate or mask ab- 
dominal dropsy, and interfere with the formation of an accurate diagnosis. 
The fluid may be so small in quantity that it occupies the pelvis only ; it 
may then, however, often be detected by making the patient rest on his 
knees and elbows so as to allow it to gravitate to the neighborhood of the 
umbilicus. It may be so abundant that the stomach and bowels fail to 
reach the surface; in which case the dulness may in all positions of the 
body continue general, excejDting, perhaps, in the course of the ascending 
and descending colon ; but here fluctuation will almost certainly be well 
marked. Or adhesions may limit the distribution and mobility of the 
ascitic fluid ; or there may be adventitious growths in the abdominal 
cavity ; or the parietes may be fat or oedematous. 

In most cases ascites causes pretty uniform distension ; but in some, 
where pouches exist, or the parietes are specially thin and yielding, this 



I 
i 



ASCITES. 



657 



uniformity" becomes interfered with. Thus hernial sacs, whether at the 
i umbilicus or at the groin, get distended with fluid; and in temales .the 
| recto- vaginal pouch sometimes becomes so much dilated that it protrudes 
through the vulva in the form of a tumor, carrying with it as a covering 
the posterior wall of the vagina. 

OEdema of the lower extremities and genitals is a common and early 
accompaniment of ascites. It sometimes occurs so early that the patient 
] observes it before his attention is particularly directed to the condition of 
his belly. It is doubtless due (when thus limited and unconnected with 
cardiac or other equivalent disease) to the pressure exerted by the ascitic 
I fluid on the iliac veins, and is generally fairly equal in the two limbs. 
Shortness of breath is an early symptom. It depends on the mechanical 
impediment which the accumulated fluid opposes to the descent of the 
diaphragm, and increases, therefore, with the increase of accumulation, 
j It is sometimes so slight that the patient only observes it when he exerts 
j himself; sometimes it is exceedingly distressing; and it is usually in- 
creased when he lies down. The lower parts of the lungs are apt to 
become empty of air and collapsed. More or less abdominal discomfort or 
pain, mainly in the lumbar regions and about the umbilicus, generally 
arises in the course of the affection. This is often of an aching, flatulent, 
or colicky character, and is probably due in some degree to the pressure 
which the fluid exerts on the hollow viscera and other organs. Sometimes 
it is peritonitic, and indeed the supervention of acute or subacute perito- 
nitis is not rare in the later stages of ascites. Although early in the 
affection there may be no visible morbid condition of tongue, and 
neither thirst nor loss of appetite, the tongue and the digestive functions 
| become after a while variously and more or less seriously affected. Diar- 
rhoea especially is a by no means uncommon complication ; and is due, 
sometimes to the same impediment to the portal circulation as causes the 
ascites, sometimes to slight dysenteric disease. There is also generally 
some 'dryness of skin and diminution of the urinary secretion. Other 
symptoms more or less grave are usually presented by ascitic patients ; 
but they are for the most part the symptoms of the morbid conditions 
on which the ascites itself depends, and are sufficiently considered else- 
where. 

Treatment. — The treatment of ascites merges, in a large proportion of 
cases, in the treatment of the diseases. out of which it arises. Still there 
are many cases in which sooner or later special treatment directed against 
the ascites itself is demanded. To promote the absorption and removal 
i of the dropsical accumulation there are good theoretical reasons for the 
employment of those remedial measures which increase the discharges 
from the skin, the kidneys, and the bowels. For diaphoretic purposes we 
must not forget the value of the hot bath, the vapor bath, and the Turkish 
bath. Among diuretics must be especially signalized iodide of potassium, 
copaiba, and the combination of crude mercury, fresh squills, and digitalis, 
j Of purgatives, those which promote watery evacuations are obviously the 
j most likely to prove efficacious. We are bound, however, to state that, 
| while acquiescing in the importance of restoring, so far as may be, or of 
j maintaining, the healthy action of the skin and kidneys, and of acting 
freely on the bowels, we have never been satisfied of the efficacy of such 
I measures in causing the removal of the dropsical fluid. And indeed, as 
j regards purgatives, we have frequently had to discard them because, while 
not distinctly benefiting the dropsy, they were in other ways obviously 
42 



658 



DISEASES OF THE DIGESTIVE ORGANS. 



affecting the patient's health injuriously. Further, the diarrhoea which 
comes on spontaneously in the course of ascites is not only not curative, 
but is difficult to arrest, and very often of bad augury. In a large number 
of cases, no doubt, all medicines are alike inefficacious ; but there are many 
in which the general improvement of the patient's health, no matter how 
brought about, is followed by the subsidence of the dropsy. Tonics, of 
which quinine, iron, and cod-liver oil are probably the best, are especially 
valuable in this respect. It is certain that they are often well borne by 
ascitic patients, and that, even when not well borne at first, a little judi- 
ciousness in their selection and mode of exhibition renders them tolerable ; 
and it is certain that often, under their use, patients not only improve in 
general health, but lose in part or wholly their dropsical accumulations, 
and that occasionally their recovery is permanent, and permanent even 
after the performance of paracentesis. Local applications to the abdomen 
are only needed to relieve pain or uneasiness ; but when the abdominal 
distension becomes so great as to cause the patient serious suffering or dis- 
tress, the fluid must be removed by tapping. This operation is usually 
delayed as long as possible, and on the whole no doubt properly so. There 
is nevertheless reason to believe that the beneficial effect of remedies is 
sometimes exerted much more markedly immediately after it than while 
the abdomen is full of fluid. Paracentesis, though usually a harmless 
operation, is sometimes followed by peritonitis. It is rarely of even tem- 
porary benefit in the ascites which accompanies malignant disease. 



XVII. HEMORRHAGE. HiEMATEMESIS. MELiENA. 

Definition — When blood is vomited the affection is termed ' hcemate- 
mesis ;' when blood is passed by stool and is of a black color, as it usually 
then is, the term 4 melcena' is applied. 

Causation. — Gastro-intestinal hemorrhage may be due : either to the 
influence of diseases, such as the infectious and malarious fevers, purpura, 
and scurvy, in which the quality of the blood is altered ; or to mechanical 
impediments to the passage of blood through the portal system or any of 
its tributary branches ; or to congestion, inflammation, breach of surface, , 
or morbid growths, involving any part of the mucous membrane. It 
occasionally also occurs vicariously of menstruation. 

Profuse hemorrhages arise mainly, from chronic ulcers of the stomach 
or duodenum, or from general hyperemia of the gastro-intestinal mucous | 
membrane, due either to cirrhosis of the liver or to obstruction of the por- 
tal trunk. Besides these causes must be especially named carcinomatous j 
and villous growths of the stomach and bowels, and the rupture of aneu- 
risms. Copious hemorrhage sometimes also takes place from typhoid or 
dysenteric ulcers. But it must not be forgotten that hemorrhage, which 
must be regarded clinically as hsematemesis, often comes from the oeso- 
phagus, and may then be due to malignant disease causing perforation of 
the oesophageal, intercostal, or other neighboring vessels, or to the rupture 
of aortic or other aneurisms or of dilated veins ; and, further, that blood 
vomited from the stomach may have been previously swallowed, as some- 
times happens accidentally in epistaxis, or designedly and for the purpose 
of deception. 



HiEMATEMESIS AND MEL^NA. 



659 



Symptoms and progress — It may be taken as a rule to which there are 
few exceptions that blood discharged from, any part of the alimentary canal 
below the duodenum, is voided solely by the anus with the feces. And 
although hemorrhage from the stomach, duodenum, or oesophagus, is no 
doubt, in a large number of cases, attended with more or less obvious 
haematemesis, it must not be forgotten that in almost all cases a larger or 
smaller quantity of the blood which finds its way into the stomach is passed 
onwards into the bowels, and that in some the whole bulk of it is thus 
transmitted. These are facts of great importance, inasmuch as abundant 
gastro-intestinal hemorrhage may take place, and may continue for some 
length of time, causing progressive and extreme anaemia, without reveal- 
ing its presence to the patient himself or to the medical man who fails to 
investigate the condition of the stools. 

The recognition of blood in the vomit or feces is not generally difficult. 
If it escape in small quantity, into either the stomach or the intestine, it 
becomes mingled with the other contents of the viscus, which acquire a 
grumous, coffee-ground, sooty, or pitchy character. And, however abund- 
| ant it may be, the longer its detention in the alimentary canal, or the 
j longer the journey which it has to perform along it, the darker and blacker 
1 as a rule it appears at the time of its discharge. Under other circum- 
! stances it may be voided almost pure, sometimes fluid, sometimes coagu- 
i lated, and, though generally of a dark hue, in some instances of a vivid 
arterial tint. If there be a doubt as to the presence of blood, the micro- 
scope will probably clear it up. When, however, the blood-corpuscles are 
wholly destroyed, and blood-pigment alone is left, some difficulty of iden- 
tification may be experienced, and it may be necessary to have recourse 
to chemical investigation or to the spectroscope. It is of course important 
not to confound the discoloration of the vomit and feces, due to articles of 
' diet (port wine and the like), to drugs (iron, bismuth, and mercury), or to 
bile, with that dependent on the presence of blood. 

Small hemorrhages are in themselves of little moment ; their frequent 
repetition, however, necessarily tends to induce more or less marked anae- 
mia, and the various symptoms which attend anaemia. Large hemorrhages, 
on the other hand, are alarming in their immediate symptoms, and of ex- 
treme danger to life. 

The occurrence of copious bleeding into the gastro-intestinal canal is 
usually attended with sudden faintness ; sometimes, indeed, the patient 
falls down insensible and convulsed. The phenomena are those of the 
rapid abstraction of a large quantity of blood, but are also not unlike 
such as may attend the sudden effusion of blood into the substance of the 
brain, or the commencement of an epileptic seizure. From this attack of 
faintness, the patient usually soon recovers somewhat; and then, if the 
hemorrhage have taken place into the stomach, he probably ere long 
vomits a more or less considerable quantity of blood — sometimes as much 
j as a quart or two at one time, or within a short period — and, later on, 
j passes a greater or less bulk of pitchy matter by stool. In some cases, as 
has been pointed out, no vomiting of blood takes place, but melaena alone 
i supervenes. The recognition of the initial symptoms as due to gastro- 
! intestinal hemorrhage rest on the supervention of haematemesis, or melaena, 
j or both. 

The further progress of such cases depends largely upon their cause. In 
some instances, the patient dies from sudden faintness, or falls into a con- 
dition of collapse from which he never recovers. In some he is suffocated 



660 



DISEASES OF THE DIGESTIVE ORGANS. 



1 



by the entrance of blood into the air-passages. In some the hemorrhage j 
is repeated over and over again, the patient becomes excessively anaemic, 
the usual symptoms due to recurrent losses of blood ensue, and at length 
death occurs. In some cases, of course, he makes a good recovery, and 
possibly never has a return of his malady. A curious occasional pheno- 
menon, in connection with profuse haematemesis, to which Lenke calls spe- 
cial attention, and which we have witnessed, is the sudden occurrence of 
double amaurosis ; in which the ophthalmoscope reveals only unnatural 
whiteness of the optic nerve and diminution of the retinal arteries, and 
which appears to be, for the most part, incurable. 

Treatment — An accurate diagnosis of the cause and seat of bleeding in 
hasmatemesis and melaena is very important in reference to treatment, and 
must rest partly on close observation of the phenomena which the case 
presents, partly on a careful inquiry into its history, but is in many cases, 
at least for a time, absolutely impossible. There are certain measures, 
however, which, under any circumstances, should be taken. The patient 
should be placed and kept in the supine position, forbidden to make mus- 
cular exertion, and guarded from all causes of mental excitement ; the 
stomach and bowels should be kept, as far as possible, at rest, and hence 
generally purgatives and emetics, solid food and stimulants, should be es- 
chewed, and fluid food should be given in small quantities ; and the force 
of the circulation should be restrained, a result which is in some degree 
attainable by perfect quiescence of mind and body, by keeping the outer 
surface only moderately warm, and by the use of certain medicines, of 
which digitalis and lead are amongst the most valuable. Simple styptics 
are not generally of much use in restraining hemorrhage, unless they can 
be directly and well applied to the bleeding surface ; and hence their 
value is not generally very great in restraining gastro-intestinal hemor- 
rhage. It can, however, at least do no harm to employ them. Among 
such remedies may be named perchloride of iron, sulphuric acid, tannic I 
acid, and turpentine. Ice and ice-cold drinks are serviceable, as well for 
their astringent as for their sedative influence. Ice may also be applied 
with benefit to the surface of the chest or abdomen. When we have 
reason to believe that the hemorrhage is due to an overloaded state of the 
portal system, it is commonly regarded as injudicious, if not useless, to 
attempt to restrain it. And, indeed, it is often recommended that the 
bowels should then be acted on by repeated and tolerably strong purgatives 
with the object of relieving the distended vessels. It must be remarked, 
however, that this variety of gastro-intestinal hemorrhage is probably the 
most frequently fatal of all varieties ; and that death, when it occurs, is 
generally due simply to loss of blood. It seems scarcely reasonable, there- 
fore, in such cases to promote, by stimulating the bowels, a kind of relief 
which is so dangerous to the patient's life, and which, even without such 
stimulation, is only too often fatal. The blood, indeed, which comes away 
is probably derived mainly, if not entirely, not from the overloaded portal 
system, but from the systemic arteries which feed that system, and directly 
from the congested capillaries distributed to the mucous surface. We 
should, therefore, recommend the employment not only of cold and of as- 
tringents to the alimentary tract, but of all those measures which have been 
noticed as tending to soothe and regulate the circulation. The further treat- 
ment of gastro-intestinal hemorrhage must depend on the nature of the 
primary disease from which the patient is suffering, and of the special 
features which his case from time to time exhibits. 



DYSPEPSIA. 



661 



XVIII. DYSPEPSIA. {Indigestion.) 

Definition No account of the diseases of the alimentary canal and its 

appendages would be deemed complete unless it comprised some separate 
consideration of dyspepsia or indigestion, that most common and fashion- 
able of all complaints. It is difficult, however, to know how to deal with 
it; for, on the one hand, it includes within itself all those functional de- 
rangements of the stomach which attend and help to characterize the va- 
rious diseases of that viscus, and many of those of the rest of the alimentary 
canal, and of the glandular organs opening upon its mucous surface, to- 
gether with such derangements as are connected with general morbid states 
of the system, and such as depend upon the quality, quantity, and condition 
of the alimentary matters taken into the stomach ; while, on the other 
hand, it is often regarded as the collective name for groups of morbid 
symptoms, referable to the stomach, which are independent of any dis- 
coverable local or constitutional disease. In the former point of view, 
dyspepsia ranges throughout the whole domain of clinical pathology ; in 
the latter, the advance of pathological knowledge tends day by day to re- 
strict more and more the limits of its applicability. To discuss dyspepsia 
in the former sense would be utterly beyond the scope and purport of the 
present work : to consider it strictly in the latter sense would be at once 
difficult and unsatisfactory. The most convenient course will probably be 
to consider briefly: the causes of dyspeptic symptoms; the several local 
phenomena which constitute dyspepsia ; the sympathetic and other conse- 
quences to which dyspepsia may give rise : and, lastly, its medical treatment. 

Causation The causes of dyspepsia may be conveniently divided into 

three groups : — namely, those connected with the ingestion of food ; those 
connected with morbid conditions of the stomach ; and those connected 
with derangements or diseases of other organs or of the general system. 
1. In the first group are comprised many pregnant causes of indigestion — 
causes, some of them, none the less important because they involve the 
habitual and conscious transgression of obvious sanitary laws. Among 
them may be included the following: — Imperfect mastication, or the bolt- 
ing of food, usually arising from undue haste in eating, or from defect or 
absence of teeth, or from soreness or paralytic conditions of the mouth ; 
Active bodily or mental exertion immediately before or after a meal ; 
Over-eating, whether this consist in a single surfeit, or in that habitual 
indulgence to excess of which so many of us are guilty, and which is espe- 
cially injurious if it go along with sluggish sedentary habits; Insufficiency 
of food; Improper arrangement of meals, such, for example, as the taking 
of one meal only during the twenty-four hours, or the crowding of all one's 
meals within a period of eight or ten hours, leaving the remainder of the 
four-and-twenty without any, or the practice (included to some extent 
i under the last head) of interpolating meals between the more important 
j meals, and thus refilling the stomach ere it has had time to rid itself of its 
previous load ; Injudicious admixture of foods — of the frequently injurious 
influence of the admixture of many different kinds of even wholesome 
articles of diet there can be no doubt ; it is difficult, however, to lay down 
any exact rule in regard to this matter, for, within limits of moderation, 
variety is conducive to health, and the too strict limitation to one or two 
kinds of food not unfrequently proves as detrimental as excessive hetero- 
geneous indulgence ; the use of indigestible or unwholesome aliments — this 



662 



DISEASES OF THE DIGESTIVE ORGANS. 



might serve as the text for a very wide discussion ; it is sufficient, how- 
ever, to point out here that, in addition to substances which may be re- 
garded as generally more or less injurious, there are many which become 
injurious only from the circumstances or conditions under which they are i 
taken, or from temporary or permanent peculiarities in the constitution 
of the sufferer, or in the condition of his digestive organs ; thus sometimes 
mutton, pork, veal, game, or shell-fish disagrees, sometimes pastry, milk, 
or eggs, sometimes different forms of vegetables or fruit, sometimes tea or 
coffee. To these causes may be added the abuse of alcoholic stimulants, 
or of tobacco, and the excessive indulgence in condiments, and perhaps 
also the habitual abstention from certain kinds of food which are essential 
to the due maintenance of the integrity of the organism. 2. The second 
group of causes — that which embraces the morbid conditions of the stomach 
itself — is necessarily also a very extensive group. It includes, moreover, 
all those morbid conditions which have already been described, and the 
presence of any one of which removes the case from among the dyspepsiae 
in the restricted sense of that term. The following is a list of the more 
obvious of the conditions here adverted to: — Catarrhal inflammation and 
congestion of the mucous membrane, which are amongst the most persistent 
causes of dyspeptic symptoms, and are often the immediate cause of such 
symptoms attending the various alimentary abnormalities just enumerated; 
Gastric ulcer ; Carcinomatous and other morbid growths; Abnormal dila- 
tation of the stomach, whether this be of primary origin, depending upon 
inherent feebleness of the walls or habitual overloading of the organ, or 
whether it be secondary to pyloric or other obstructions to the onward 
passage of alimentary matters ; Diminution in size, whether arising from 
the gradual contraction of infiltrating growths of the gastric walls, or from 
long-continued abstinence, or from spasmodic action of the muscular coat 
referable to irritability of the mucous surface or other sources of reflex 
action ; Degenerative changes of the mucous membrane, such as may result 
from chronic catarrhal inflammation, or the abuse of alcohol, or may arise 
in the course of chronic wasting diseases; And, lastly, functional derange- 
ments, including irritability, and excess, diminution, or derangement of 
the gastric secretions. 3. The third group of causes again is one of very 
great extent. It includes all those conditions of the alimentary canal — 
constipation and the like — which react on the functions of the stomach ; 
all those morbid states of surrounding organs which lead to pressure on the 
stomach and interference with the performance of its duties ; all those 
lesions of the portal system, lungs, heart, and kidneys, which, by impeding 1 
the circulation, induce congestion or other abnormal conditions of the 
stomach ; all those disturbances of the nervous system (among others power* 
ful mental impressions or emotions, and the reflex phenomena of early 
pregnancy) which influence the actions of the stomach; and, further, all 
those general diseases — anaemia, pulmonary phthisis, fevers, and innumerable 
others — of which difficult, painful, or faulty digestion forms an appreciable, 
if not a prominent, symptomatic feature. 

Symptoms. 1. Referable to the stomach The symptoms which attend 

and indicate dyspepsia are to a large extent those which also accompany 
in a greater or less degree the Various organic lesions of the stomach. 
They comprise derangements of appetite, derangements of sensation, flatu- 
lence and eructation, nausea and vomiting. 

The appetite in dyspeptic patients is very variable. In some cases it 
remains but little affected, or there is simply a distaste for certain articles 



DY.SPEPSTA. 



663 



i of diet ; or without there being any actual distaste, experience shows that 
certain alimentary matters formerly taken with impunity now induce 
various discomforts. In many cases there is more or less loss of appetite, 
and occasionally this amounts to absolute repugnance to all forms and 
1 varieties of food. In many cases, again, a persistent sense of uneasiness 
or emptiness, with constant craving for food, is a marked phenomenon ; it 
occasionally happens that the appetite is absolutely increased ; more fre- 
quently, however, the craving is changed by the ingestion of even small 
j quantities of food into some other sensation of discomfort, which brings 
| the meal to a speedy close. Now and then, and especially in hysterical 
I females, the appetite becomes depraved — the patient not merely craving 
for aliments which are of an unwholesome character, but swallowing earth, 
coals, chalk, or other substances which are either wholly devoid of ali- 
mentary virtues, or disgusting, or absolutely injurious. Thirst may or 
may not be present. 

The abnormal sensations which attend dyspepsia are of different kinds. 
There is generally more or less uneasiness or pain. A sense of weight, 
sinking, fulness, shooting, aching, or burning, referred to the pit of the 
stomach or some neighboring part, or to the inter-scapular region, is rarely 
absent. In some cases this comes on mainly when the stomach is empty, 
and disappears under the influence of a meal ; in some it comes on wholly 
after food, and lasts during the whole period of gastric digestion ; in some 
it is more or less constant, being present when the stomach is empty, and 
getting aggravated or modified after a meal. In other cases pain comes 
on some little time after food has been received into the stomach, it may 
be in the course of a quarter or half an hour, or after the lapse of two, 
three, or four hours. Another form of gastric pain is described as con- 
nected with dyspepsia, namely, a pain of great intensity, frequently 
likened to that of cramp, which comes on at irregular and often rare inter- 
vals, which lasts a variable time, and is usually attended with marked 
symptoms of faintness or collapse, and often in women with hysterical 
phenomena. This pain, which is not uncommon in gouty persons, occu- 
pies the usual position of gastric pains, but shoots in various directions, 
upwards into the chest and downwards into the abdomen. There is no 
doubt that this variety of gastrodynia is largely confounded with that due 
to the passage of gall-stones, and with pains originating in various other 
than gastric sources. Epigastric tenderness is not usual. 

Flatulence and eructation are generally complained of by dyspeptics in 
a greater or less degree. Flatulence usually goes along with sense of ful- 
ness or distension of the stomach, and other of the uneasy or painful feel- 
ings which have been considered. The accumulation of gas is indicated 
also by actual distension of the epigastric region, and the occurrence of 
gurgling and other noises within the stomach ; it moreover gives rise to 
eructation. Eructation, which is generally attended with more or less 
relief to the patient, is often noisy, and effected with powerful and uncon- 
trollable spasmodic action of the muscles. The amount of wind thus dis- 
charged is sometimes enormous ; and at the same time it is so sudden in 
its evolution that it has been assumed to be secreted by the mucous mem- 
brane of the stomach and bowels. Of this, however, there is no proof; 
and indeed there can be no doubt that it is really derived from decomposi- 
tion of the food. The gases consist of carbonic acid, hydro-carbons, and 
in some cases sulphuretted hydrogen. Together with these, small quanti- 
ties of the contents of the stomach are not unfrequently brought up. In 



664 



DISEASES OE THE DIGESTIVE ORGANS. 



some cases the quantity of matter thus discharged without sensation of sick- 
ness or material effort is very considerable ; and the process by which it is 
returned is sometimes termed rumination. 

Nausea and sickness, again, are frequent symptoms of dyspepsia, and 
are sometimes exceedingly distressing. In many cases of functional dys- 
pepsia, as in that of pregnancy, nausea often goes along with increased 
appetite. Sickness is usually preceded by nausea, and occurs at different 
times and with various degrees of severity. In some cases it comes on 
when the stomach is empty ; more frequently it occurs shortly after inges- 
tion ; sometimes it does not happen until an hour or two after a meal ; 
and occasionally it takes place at irregular and long intervals. The 
material vomited presents considerable variety : in some cases it is simply 
the food but little altered ; in others it is an alkaline ropy mucus ; in 
others it consists mainly of the ordinary acid juices of the stomach ; in 
others it is a neutral watery fluid having many of the characters of the 
salivary secretion. In other instances (and especially when the vomiting 
does not take place until long after the ingestion of food) the vomited 
matters have undergone fermentation : they are acid from the development 
of acetic, lactic, and butyric acids, and present, on standing, a brownish 
frothy scum and a more or less abundant sediment ; or else they have 
undergone putrefactive changes and have an offensive, occasionally rotten- 
egg-like, occasionally almost fecal, odor. The vomit presents as much 
variety in quantity as in quality ; sometimes it is scanty, and little more 
abundant than occurs in eructation ; at other times it is discharged in 
enormous quantities. The latter occurrence is most frequent when the 
vomiting comes on some hours after a meal, or at irregular and compara- 
tively long intervals, and therefore in cases of obstructive disease of the 
pylorus, or when the stomach, from whatever cause, is abnormally dilated 
and sluggish or enfeebled. It may be observed that vomiting immediately 
after food is generally indicative of irritability of the stomach ; that the 
discharge of abundant ropy mucus usually implies the presence of inflam- 
mation ; that fermentative and putrefactive changes point to long reten- 
tion of alimentary matters in the stomach, and possibly also to some defect 
of relation between the quantity of food ingested and the quantity of gastric 
fluid secreted ; and that always after long-continued vomiting the contents 
of the duodenum, inclusive of bile, regurgitate into the stomach, and thus 
mingle with the vomit. When fermentation takes place, the torula cere- 
visiie may always be discovered in great abundance in the vomited matters, 
and it is usually under similar circumstances that the sarcina ventriculi 
also may be recognized. 

The term pyrosis is generally used of those cases in which a clear fluid 
is vomited or eructated, for the most part in connection with more or less 
severe epigastric pain, and at times when the stomach is empty, or nearly 
empty, of food. The quantity of fluid brought up at one time may vary 
from a few teaspoonfuls to several pints. It is usually neutral, but may 
be alkaline or acid. Both by Budd and by Frerichs this fluid, when of 
neutral reaction, is looked upon as being saliva which has been swallowed. 
Pyrosis is not unfrequently connected with organic disease of the stomach ; 
but in its most typical form is either functional or due to the constant use 
of certain irritating articles of diet. It is said to be especially common 
among the lower classes in Scotland and Lapland, and to be dependent on 
the quality of their food. 



DYSPEPSIA. 



665 



2. Referable to other organs. — Among the many secondary phenomena 
of dyspepsia, those connected with the remaining regions of the alimentary 
canal first claim attention. The tongue varies in character ; it is some- 
times clean and healthy, sometimes pale and flabby, sometimes more or 
less thickly coated, and sometimes cracked or fissured. The bowels are 
for the most part constipated, but there may be persistent diarrhoea, and 
not unfrequently there is considerable irregularity of action. In some 
cases of indigestion, attended with looseness of bowels, undigested food in 
considerable abundance is found in the stools. It is obvious that in these 
cases the passage of the contents along the bowel is exceedingly rapid ; 
and in many of them, according to Trousseau, whose experience is con- 
firmed by that of Dr. Wilson Fox, there is at the same time large appetite, 
with rapid escape of food from the stomach, and rapid consequent renewal 
of appetite. Trousseau assumes that there is excessive irritability of the 
muscular walls of the stomach and bowels, and that it is on this account 
that the food is carried too swiftly onwards. The urine is frequently 
affected, and may contain an excess Of phosphates, oxalates, or urates, the 
last not unfrequently being deposited as a lateritious sediment. The action 
of the heart is commonly quickened, but is sometimes slower than natural, 
and often variable. Dyspeptic patients are liable to palpitation and irregu- 
larity of action, coming on especially after meals or in the night. Dyspnoea 
is apt to attend the attacks of palpitation ; and a variety of asthma has 
been referred to the presence of indigestion. Dyspeptic patients are liable 
in a peculiar degree to certain forms of skin disease, such as urticaria, 
erythema, lichen, and eczema, but above all, perhaps, to acne rosacea, and 
other allied conditions manifesting themselves upon the nose and cheeks. 
Elevation of temperature and other distinct febrile symptoms are no neces- 
sary features of dyspepsia ; but they may appear if the dyspepsia be con- 
nected with inflammatory affections of the stomach. The influence of 
dyspepsia and of other morbid conditions of the stomach on the functions 
of the nervous system is very remarkable. Vertigo, headache, intolerance 
of light or sound, depression of spirits, irritability, hypochondriasis, sleep- 
lessness, and various forms of neuralgia, are all of common occurrence. 
The severer forms of dyspepsia, and especially those in which there is 
much sickness, are usually attended with more or less debility and emacia- 
tion. Indeed, purely functional affections of the stomach, attended either 
with total loss of appetite, or with constant vomiting after food, occasionally 
induce a degree of emaciation and debility rivalling that which one meets 
with in the last stages of carcinoma of the cardia or pylorus, or of pulmo- 
nary phthisis with intestinal ulceration. On the other hand, it is often 
curious to observe how, notwithstanding incessant vomiting, patients retain 
a fair amount of plumpness. 

Treatment. — The treatment of dyspepsia is a subject of considerable 
importance and no little difficulty, and demands a good deal of firmness, 
savoir /aire, sound judgment and readiness of resource on the part of the 
physician, and often at the same time no little trust and resolution on the 
part of the patient. The first thing to be done is to ascertain as far as 
may be the circumstances to which the dyspepsia owes its origin, or those 
which determine its continuance, and, if possible, to cure or obviate them. 
With this object, it may be of essential importance : to insist on the proper 
comminution of food, to see that the teeth are in good order, and if not 
that they are supplemented or replaced by false ones, or that artificial 
mastication is employed, and that the patient gives ample time to his eat- 



666 



DISEASES OF THE DIGESTIVE ORGANS. 



ing ; to regulate the distribution of the meals, so that, if they be full meals, 
they shall be separated by intervals of four or five hours at least, or if, 
from any circumstance, the patient is compelled to take only small pro- 
portions of food at any one time, the intervals between them shall be cor- 
respondingly reduced ; to regulate the quantity of food taken at each meal 
and daily, in the sense of neither letting it fall below what is required, nor 
of permitting any great excess ; to insist that the food taken shall be 
wholesome and readily digestible, and that especially any article of diet 
which experience has shown to be injurious shall be strictly abjured. There 
are considerable differences in regard to the articles of diet which are most 
suitable for different dyspeptics ; and, in order to treat successful^, it is 
often important to study each patient's peculiarities in this respect. It 
may be stated generally, however, that all rich and greasy compounds and 
fat are likely to disagree ; that fish, flesh, and fowl (whichever he selected) 
should be well cooked ; that raw vegetables should be eschewed ; that in 
a large number of cases (and especially those in which the stomach is irri- 
table or inflamed) milk and farinaceous foods and eggs are of especial 
value; that ripe fruits are admissible and often beneficial; and that alco- 
holic beverages should be only moderately indulged in. In many cases 
total abstinence from alcohol is imperatively demanded. Again, it is 
always important : to ascertain the morbid condition, if there be any, 
under which the stomach is laboring — if inflammation, ulcer, or growth of 
any kind be present, if there be obstruction at the pylorus or at the cardia, 
if the stomach be dilated or contracted, and so on; and to determine the 
treatment in accordance with the nature of the lesion which is present. It 
is of equal importance to ascertain whether the dyspeptic symptoms are 
secondary to any constitutional disturbance, such as anaemia, phthisis, or 
gout, which happens to be associated with them, in order that we may 
direct our treatment to the relief or cure of the essential disease. 

The above remarks are not intended to distract attention in any degree 
from the actual symptoms which cause the patient's sufferings. These 
generally need special treatment ; but, guided by the principles which have 
been laid down, we may in most cases so select or so combine our reme- 
dies as, on the one hand to relieve local symptoms, on the other to remedy 
the conditions out of which the dyspepsia has arisen. 

Loss of appetite is often very difficult of treatment. It may, however, 
in some cases be overcome by the use of vegetable tonics, especially gen- 
tian, quassia, calumba, or the liquid extract of cinchona, in combination 
with small quantities of rhubarb, aromatics, and an alkaline carbonate ; or 
by the employment of quinine, strychnia or iron, or (if there be constipa- 
tion) of aperients, especially rhubarb and aloes, in combination with aro- 
matic bitter. But food has often to be administered when the patient has 
not only no desire, but possibly even a loathing for it. It is then necessary 
either to study the patient's fancies by making frequent variations in the 
food which is placed before him, or to administer food of a wholesome and 
suitable character in small quantities and at short intervals. It is some- 
times necessary indeed to employ nutrient enemata, and for a time par- 
tially or altogether to discontinue the use of food by the mouth. 

Gastric uneasiness or pain needs different treatment according to the 
circumstances under which it arises or the conditions to which it is imme- 
diately due. When it occurs mainly during the period in which the 
stomach is empty, the obvious remedy is the ingestion of food ; it may then 
be necessary to take meals at more frequent intervals than in health, or to 



DYSPEPSIA. 



667 



relieve the uneasiness in these intervals by taking a biscuit or some other 
light and easily digested refreshment. It not unfrequently happens that 
persons otherwise healthy who have nothing after their dinner at five, six, 
or seven o'clock, wake in the middle of the night with more or less gas- 
tralgia, or complain of similar pain with nausea and perhaps sickness in 
the morning. The proper treatment for such cases is the taking either of 
a light supper before going to bed or of a light meal before rising in the 
morning. When pain occurs immediately after the ingestion of food it 
implies the presence of some morbid irritability, inflammation, or organic 
mischief in the walls of the stomach, and may be treated partly by regula- 
tion and selection of diet, and partly by the use of drugs, such as nitrate 
of silver, hydrocyanic acid, or bismuth, given before food. If the pain be 
dependent on flatulent distension, peppermint, ginger, and other carmina- 
tives are generally useful. Mineral acids and the earthy or alkaline car- 
bonates, are often valuable in relieving pain, as they are in relieving other 
dyspeptic symptoms. It is not always easy to determine a priori which 
remedies are best suited for any particular case. It may, however, be 
assumed as a general rule that, when the secretions of the stomach are 
alkaline or neutral, as they are apt to be in inflammatory conditions, acids 
are indicated ; that when they are acid, alkalies, if not specially indicated, 
are at all events more suitable. Opium is of great value in the relief of 
gastric pain, and may frequently be advantageously combined with other 
remedial agents, especially perhaps with bismuth or kino. When the gas- 
tralgia is severe, and especially if it be of a spasmodic character, and asso- 
ciated with faintness or collapse, opium may be regarded as our sheet- 
anchor. It should be given in large, and, if necessary, repeated doses. 
Blisters and other counter-irritants, or fomentations to the epigastric re- 
gion, are often useful. 

For flatulence and eructation, carminatives, and more especially the 
essential oils, some of the oleo- or gum-resins, ammonia, or brandy in small 
quantities, are generally beneficial ; but they are beneficial rather by 
assuaging present uneasiness and dispersing wind by eructation than by 
any direct curative influence. For relieving these conditions, however, as 
well as for checking vomiting, careful attention to the quality, quantity, 
and times of administration of food must always be paid. 

Nausea and vomiting may be benefited by various agents : by ice in 
small quantities ; by the alkaline carbonates, which may often be advan- 
tageously given in an effervescing form with lemon-juice or citric or tartaric 
acids; by oxalate of cerium, carbonate of magnesia, lime-water, bismuth, 
nitrate or oxide of silver, hydrocyanic acid, or creasote. When flatulence, 
eructation, and vomiting are dependent on, or associated with, fermenta- 
tion or putrefaction of the contents of the stomach, special treatment may 
be called for; fermentation may be checked by the use of creasote, sulphite 
of soda, or sulphurous acid ; putrefaction by the exhibition of the mineral 
acids and more especially hydrochloric acid, with which pepsine may be 
combined. 

In pyrosis or water-brash the above forms of treatment may be service- 
able, but generally bismuth alone or combined with opium, or the vegetable 
astringents conjoined with a narcotic — the compound kino powder, for 
example — appear to have a special value. In cases in wdiich the stomach 
is excessively dilated it has been recommended to empty the organ from 
time to time by means of the stomach-pump, and then to wash it out. 



668 



DISEASES OF THE DIGESTIVE ORGANS. 



Lastly, it must never be forgotten that in all cases of chronic dyspepsia 
hygienic treatment, inclusive of moderate exercise, regulated hours, well- 
ventilated rooms, and change of air and scene, is of considerable im- 
portance. 



XIX. DIARRHOEA. 

The term diarrhoea, like the term dyspepsia, is applied to a symptom or 
group of symptoms which is common to a wide range of morbid conditions, 
of which the majority are discussed with more or less completeness in 
various parts of this volume. It is needless, therefore, as well as inappro- 
priate, to enter upon the subject here at any great length. 

Causation Diarrhoea is of common occurrence at some period or other 

in the course of many febrile or other constitutional maladies. It not 
unfrequently complicates hepatic and splenic diseases, and other affections 
which induce undue congestion of the portal vessels and their tributaries. 
It is one of the ordinary consequences of organic lesions, of whatever kind, 
of the mucous membrane of the bowels. It is frequently induced by 
inflammatory conditions of the same tract, by the ingestion of unwholesome 
or irritating articles of food, and by over-eating. It is certain also : that 
it is sometimes caused by nervous influences, and especially by anxiety, 
fear, and allied mental emotions ; and that excessive or perverted secretion 
from the alimentary canal, or from the glands which open upon it, has a 
large share in its production. Among circumstances which exert an im- 
portant influence in causing diarrhoea, are age, habits, and season, with 
other climatic conditions. Thus it is peculiarly frequent amongst young 
children, especially at or about the times of weaning and teething; again 
it, or its converse — constipation — is very apt to follow upon dietetic and 
other changes of habit; and, further, the influence of hot weather, and 
especially in this country of the later summer months, and of alternations 
of temperature, in its causation is a well-known fact. 

In considering the pathology of diarrhoea, we shall first discuss -the 
influence of the contents of the gastro-intestinal canal in its causation. It 
is the presence of alimentary matters which, in conjunction with that of 
the normal secretions, excites those peristaltic movements which terminate 
with defecation. The bowels as well as the stomach are no doubt in many 
cases very long-suffering ; yet, notwithstanding this, they are frequently 
stimulated to unwonted action by the matters which gain entrance into 
them. Excess of even wholesome food, the ingestion of difficultly diges- 
tible or unwholesome matters, the use of polluted water, even the trans- 
mission from the stomach of imperfectly reduced contents, or of such as 
are undergoing fermentation or putrefaction, are all likely to cause more or 
less intestinal disturbance, with consecutive diarrhoea. Again, excessive 
discharges from the liver or intestinal surface, especially if they assume 
an inflammatory character, do, even when themselves determined by the 
influence of irritating alimentary matters, materially promote the abnormal 
action of the bowels. Amongst causes of intestinal irritation must also 
be included prolonged constipation, or excessive accumulation of feces. 

Of the important part which the mucous surface of the bowels plays in 
relation to diarrhoea there is no room for doubt. It is, in fact, by the 
influence of the contents on this surface that they are themselves influential 



DIARRHOEA. 



669 



in causing it. The conditions of the mucous membrane which promote 
diarrhoea are (omitting morbid growths, degenerative changes, and other 
destructive lesions) irritability, irritation, and catarrhal inflammation. In 
the first case, the over-sensitive surface resents the contact of the normal 
intestinal contents, and excites the muscular walls to propel them rapidly 
onwards ; in the second, the healthy intestinal walls are excited to un- 
wonted action and over-secretion by the irritating matters which are in 
contact with them ; in the last there is actual inflammation present, with 
more or less important change in the character and quantity of the secreted 
juices. 

Without the action of the intestinal muscular walls, diarrhoea could not 
exist ; it is owing indeed to their powerful and frequently-recurring peris- 
taltic movements, for the most part reflectorially excited from the mucous 
surface, that the contents of the bowels are carried onwards with unwonted 
energy. But their action is under the immediate direction of the sympa- 
thetic nerves, and it is quite possible (as has been proved experimentally) 
for energetic peristalsis to be excited by the direct irritation of these nerves, 
and hence for similar movements to be induced through their agency by 
causes originating in the central nervous organs or other remote sources of 
irritation. Trousseau, indeed, refers one form of diarrhoea, as well as one 
form of dyspepsia which is commonly associated with it, to increased 
tonicity of the intestinal and gastric muscles — a condition which, if it 
exist, is evidently dependent on nervous agency. The influence of depress- 
ing passions in causing diarrhoea is exerted obviously through the nervous 
system ; but whether this operates by simply augmenting peristaltic move- 
ment, or in the first instance promoting excessive flow of mucus and other 
fluids into the intestinal canal, is a question which it would be somewhat 
difficult to decide. 

Symptoms and progress. — By diarrhoea we mean strictly the actual dis- 
charge from the anus of unformed or fluid motions in greater quantity or 
more frequently than natural. But owing to the remarkable length of the 
alimentary canal, and to the variations in its structure and functions in 
different parts of its course, we may have conditions which correspond 
essentially to diarrhoea developed at different parts and leading to different 
results. Thus if the affection involve the large intestine, diarrhoea (dys- 
enteric in character) will certainly ensue ; if, however, it attack the upper 
part of the jejunum, the diarrhoea (so to speak) may only occur between 
the jejunum and the ileum, or between these and the caecum : the patient 
will suffer from colic or griping, but instead of frequent loose evacuations 
there may be actual constipation. 

As regards the characters of the alvine discharges, there will necessarily 
be much variety, dependent partly on the nature of the ingesta, partly on 
the amount and quality of the secretions of the different glandular organs, 
partly on the fermentative and other changes which take place in the 
bowel, and partly on the rapidity with which the contents of the stomach 
are carried onwards to the anal orifice. We may discover in the evacua- 
tions solid masses of animal or vegetable matter, fat which has not been 
saponified, comparatively large quantities of only slightly modified starch, 
and, in young infants, coagulated but otherwise scarcely altered milk. 
They may contain large quantities of mucus, unmixed if it be secreted by 
the large intestine, incorporated and imparting pallor and fluidity if it be 
furnished by the remoter portions of the bowel. Or the discharges may 
be exceedingly copious and almost watery in character, and may contain 



670 



DISEASES OF THE DIGESTIVE ORGANS. 



either large quantities or merely traces of biliary coloring matter. Fluidity 
of the evacuations may be clue in large measure to simple hurry in the 
transmission of the contents of the bowels, and to the consequent escape 
with the feces of those natural secretions which under normal circum- 
stances would have been reabsorbed ; there is no doubt, however, that in a 
large number of cases it is dependent in a greater or less degree on exces- 
sive secretion. When fermentation or decomposition occurs, there is, at- 
tending the diarrhoea, much discharge of flatus, which is often exceedingly 
offensive ; and the evacuations, which are more or less watery and fetid, 
present a frothy or yeast-like character. Under these circumstances the 
yeast-fungus or the sarcina ventriculi may generally be discovered in them. 
When the contents are propelled along the intestinal canal with great 
rapidity, there is insufficient time for digestion, at all events for intestinal 
digestion, to be efficiently performed; and it is under such circumstances 
that the condition termed 1 lienteryj or the passage of undigested food, 
frequently takes place. We may here call attention to the fact that ovarian 
and other cysts, hydatid tumors and abscesses, may open into the bowel 
and give rise to diarrhoea! stools, of which their contents form an important 
and more or less obvious constituent. 

The essential symptoms of diarrhcea are pain and the occurrence of 
loose stools ; but with these are usually associated others of more or less 
severity and importance. Pain of an aching, griping, or colicky character 
is generally present, coming on at intervals, attended with borborygmi and 
more or less manifest movements of the bowel, and varying in its seat. It 
differs in severity, and is sometimes so intense that the patient rolls about 
or writhes in agony, and a state of partial collapse, with coldness of sur- 
face, perspirations, and feeble pulse, is induced. If it be developed high 
up in the course of the bowel, vomiting not unfrequently takes place ; if 
it occur in the lower part of the large intestine, spasmodic expulsive ac- 
tions of the abdominal muscles are excited. There is not usually abdom- 
inal tenderness ; the pain, indeed, is often relieved by pressure or friction. 
In some cases of diarrhcea, copious evacuations take place with little or no 
uneasiness or pain. The different characters of the stools have already 
been detailed. It remains to say : that the quantities discharged vary 
within wide limits, and are sometimes as enormous as they are in cases of 
epidemic cholera ; and that the frequency of the evacuations presents 
equal variety. Among the associated symptoms, which may or may not 
be present, are dryness or coating of the tongue, soreness of the mouth 
and fauces, anorexia and thirst, nausea, vomiting, and eructation, giddi- 
ness or headache, and, as has been already stated, symptoms of faintness 
or collapse, sometimes alternating with flushes of heat and slight febrile 
symptoms. When diarrhoea is profuse, and at the same time acquires a 
chronic character, innutrition with more or less rapid emaciation and loss 
of strength ensues : and death may ultimately result either from simple 
exhaustion or from the supervention of complications. 

It is scaVcely necessary to specify in detail the different characteristic 
features of the many various forms of diarrhoea which are met with in 
practice, or to insist on the extreme difficulty and frequent impossibility 
of distinguishing functional diarrhoea, which is now under consideration, 
from the diarrhoea of intestinal lesions. There are two forms of diarrhoea, 
however, which call for particular remark, namely, " infantile diarrhoea" 
and "summer (English) cholera." Although receiving different names it 
would be difficult to draw any clear line of distinction between the morbid 



DI ARRHCEA. 



671 



conditions here associated. We shall, therefore, combine their descrip- 
tion. Infants, especially at or about the time of weaning, are remarkably 
apt to be attacked with diarrhoea, and to fall victims to it ; and this tend- 
ency is greatly increased during the summer months when diarrhosal com- 
plaints are common not only in children but in adults. The attack, 
whether in the infant or the adult, sometimes comes on suddenly, some- 
times supervenes in the course of some slight gastro-intestinal disturbance. 
It usually commences with copious and repeated vomiting, first of the 
normal contents of the stomach, then of watery fluid, containing bile. 
The diarrhoea is at first characterized by the expulsion of the contents of 
the lower bowel but little altered ; but gradually the evacuations become 
more and more thin and watery, although still tinged more or less strongly 
and not unfrequently green with biliary coloring matter. [The stools in 
cholera infantum, the name by which the disease is best known in 
America, after the first few discharges which contain fecal matter in 
greater or less amount, usually consist of a thin serous liquid, either alone 
or holding in suspension small masses of greenish-colored feces. The 
discharges are generally very copious — indeed they not infrequently, after 
thoroughly saturating the diaper of the child, wet the lap of the mother or 
nurse. They are commonly without marked odor, especially when they 
are colorless. Occasionally, however, they are brownish or yellowish in 
color, and then have a very fetid and offensive smell. They may also be 
very irritating, excoriating the parts with which they come in contact.] 
With these phenomena are associated intense thirst, much pain and 
griping in the belly, which is usually retracted, and cramps in the limbs, 
together with more or less marked collapse, indicated by coldness of sur- 
face, rapidity and feebleness of pulse, pinched features, sunken eyes 
surrounded by dark circles, bluish finger-nails, sighing respiration, altered 
voice, and restlessness. The symptoms have, in fact, a close resemblance 
to those of Asiatic cholera, but differ from them clinically in the circum- 
stances : that the evacuations rarely if ever assume the rice-water charac- 
ter, or are devoid of bile ; that the urine is not generally suppressed ; and 
that the collapse is neither so sudden nor so extreme as that of the epi- 
demic disease. Nevertheless the affection is very dangerous, carrying off 
a very large proportion of the children whom it attacks, and not unfre- 
quently proving fatal to adults. If recovery take place from the stage of 
collapse, a febrile stage ensues in which the temperature rises, the surface 
assumes a normal or febrile aspect, the tongue gets red and dry, and the 
evacuations (which probably remain diarrhoeal) acquire something of a 
dysenteric character. The patient becomes dull and lethargic, and, if a 
child, falls into a condition of stupor, with moaning, plaintive cries, and 
jactitation, which may readily be mistaken for symptoms of cerebral dis- 
ease. The period of collapse lasts from a few hours to twenty-four or 
thirty-six hours ; and it is especially during this period that death is 
likely to occur. The latter stage may be continued for several days or 
for a M r eek or two. 

Treatment — The treatment of diarrhoea must depend mainly upon the 
causes to which it is due and the symptoms with which it is attended. 
When it is distinctly the consequence of alimentary errors, it is usually 
best at the commencement to aid the removal of offending matters either 
by emetics, such as mustard and water, or a full dose of ipecacuanha, or 
by purgative medicines such as hyd. c. creta, blue pill, Gregory's powder, 
compound rhubarb pill, an ordinary black draught, or castor oil. Such 



672 



DISEASES OF THE DIGESTIVE ORGANS. 



measures may effect a cure; but if the diarrhoea still persist, carminatives 
and astringents may be requisite. Of these compound kino powder, aro- 
matic chalk and opium, chalk mixture, or lime-water or bismuth combined 
with vegetable astringents, opium or rhubarb, may be efficacious. If 
these fail recourse may be had, according to circumstances, to tannic acid, 
lead and opium, copper, perchloride of iron, nitrate of silver, or sulphuric 
acid. An essential element in the treatment, however, and one which 
is alone often sufficient for the purpose, is partial or complete abstinence 
from food for a time, and subsequent limitation of the patient's dietary to 
such matters as are bland and easily digestible. Milk, arrowroot, and 
such-like substances, broths, toast, and simple well-baked biscuits are 
especially suitable. In the case of young children no purgative medicines 
probably are better than chalk and mercury, Gregory's powder, and castor 
oil ; and no combination of astringents and aromatics better than aromatic 
chalk and opium, or small quantities of catechu, opium, aromatic chalk, 
and syrup of ginger in solution. In this case, too, especial attention must 
be paid to diet. If the child has been weaned it may be necessary to 
supply it again from the breast ; or to provide it with asses' or goats' 
milk ; or to feed it with skimmed cow's milk to which lime-water may be 
added, or with well-baked flour or suitable biscuit-powder diffused or 
suspended in water or milk. If the diarrhoea be of distinctly inflamma- 
tory origin, very much the same kind of treatment is needed; purgatives 
may still be requisite in the early stages, but castor oil or salines are 
probably to be preferred. Dietetic treatment also in these cases is of 
great importance. If there be much abdominal uneasiness or griping, 
warm fomentations or mustard plasters to the parietes, or the warm bath, 
may be beneficial. 

In the choleraic form of diarrhoea, which attacks young children and 
adults, mainly in the summer time, little or nothing can be done at first to 
arrest the diarrhoeal phenomena. Trousseau regards the mustard bath 
(made by inclosing a cold paste of mustard in a muslin bag and squeezing 
this in the water of the warm bath until the latter is sufficiently impreg- 
nated) as the most powerful and efficacious remedy; and directs that it 
should be employed for about a quarter of an hour, or until the mustard 
causes some tingling of the surface, and that it should be repeated if neces- 
sary. For internal treatment the exhibition of iced water, rice-water, 
decoction of barley, skimmed milk, or the eau albumineuse of Trousseau 
(made by diluting the whites of four eggs with about If pints of water, 
sweetened with sugar and flavored with orange-flower water) may be re- 
sorted to with advantage. During the same period emetic doses of ipecac- 
uanha, and purgative doses of the hyd. c. creta are of common use and 
strongly recommended ; but if the collapse be serious, diffusible stimulants, 
such as ether, and ammonia, or some of alcoholic beverage, are demanded. 
At this period opium is a remedy of questionable efficacy, and in the case 
of young children should be carefully avoided. With the cessation of 
diarrhoea and vomiting and the supervention of febrile symptoms the diet 
above recommended must still be continued, but the medicinal treatment 
must now be that which is beneficial in catarrhal inflammation of the 
bowels, and may include such drugs as bismuth, chalk, and lime-water, 
with opium. 

Chronic diarrhoea is often very intractable, and requires much judicious 
management for its successful treatment. Hence attention to diet is of 
supreme importance. It is impossible, however, to lay down any definite 



DIARRHOEA. 



673 



rules in reference thereto. In many cases fluid nutriment- is most suitable ; 
in some, food is best administered in the solid form ; in some, the farinacea 
agree best ; in some, alimentary matters derived from the animal kingdom. 
We must be guided in each case, partly by the patient's own feelings and 
| experience, partly by the special symptoms present and the character of 
the evacuations, and partly, of course, by the opinion which we form of 
the nature and origin of the attack. In such cases it not unfrequently 
happens that the diarrhcea is kept up by the habitual use of some unsuit- 
! able article of diet, or by the constant presence of some hygienic condition 
1 inimical to the patient's health, or by the continued indulgence in habits 
which are injurious to him. It is in chronic diarrhoea (especially in chil- 
dren) that the use of raw meat, to the exclusion of all other food, has been 
I so strongly advocated. The lean of beef or mutton should be selected, 
! minced, pounded in a mortar, squeezed through a sieve, and given either 
in the form of the simple pulp, or mingled with sugar, red currant-jelly, 
or other similar substances. It should be administered at first in small 
doses, and then gradually increased. Trousseau has thus given as much 
as a pound a day to a child less than three years old. We must not 
forget the danger which, in taking raw meat, our patient incurs of becom- 
ing affected with taenia — a danger which both Trousseau and Goodeve have 
shown not to be fanciful. For medicinal treatment, we may have recourse 
to the various vegetable astringents and bitters, or to bismuth, silver, 
copper, or iron, or to the mineral acids, or to rhubarb or ipecacuanha, or 
to opium, nor must we forget the benefit which may result from the occa- 
sional administration of saline or stomachic purgatives. 

[The great mortality from cholera infantum in this country during the 
hot months of the year, renders the disease one of great interest to Ameri- 
can physicians, especially to those whose practice lies in the large cities, 
where it chiefly, indeed almost exclusively, prevails. Among its causes 
are unquestionably improper food and the intense heat of the summer, a 
heat, too, which continues with almost undiminished intensity during the 
night. But that these alone are not sufficient to produce it is shown by the 
fact that it is of comparatively very infrequent occurrence in the country, 
in the neighborhood of the cities, where the temperature is almost equally 
high, and where the diet is often unsuitable. It is therefore probable that 
among the other causes which co-operate with these are bad drainage, im- 
perfect ventilation, and overcrowding. The disease is most apt to occur 
during the first dentition, and is more common among children who are 
artificially fed than among those who are nursed. 

When the large number of children who annually fall victims to this 
disease is taken into consideration, it is rather surprising that so few post- 
mortem examinations are on record. Dr. J. Lewis Smith, of New York, 
who has enjoyed unusual opportunities for its study, has found evidences 
of inflammation of the whole of the gastro-intestinal tract, together with 
enlargement of the solitary glands, and, in many instances, of Peyer's 
patches. He therefore attributes the symptoms to these lesions. On the 
other hand, Drs. Meigs and Pepper, adopting Dr. Sedgwick's theory of 
I the pathology of cholera, and believing that symptoms closely resembling 
I those of cholera collapse maybe produced by various morbid conditions of 
the intestines, or by the ingestion of unwholesome or tainted food, includ- 
I ing milk which has undergone change, teach that the collapse in cholera 
infantum is attributable to a wide-spread and powerful irritation of the 
I branches of the sympathetic distributed to the mucous membrane of the 



| 



674 DISEASES OF THE DIGESTIVE ORGANS. 

bowels. This theory explains, as it does in cholera, many of the prin- 
cipal symptoms of the disease, such as the coldness of the surface, the ' 
small, thready, and frequent pulse, the pinched features, the holiow eyes, 
the attacks of cramp, the cold breath, and the occasional suppression of the 
urine. 

It is of the greatest importance to guard children against attacks of 
this disease. This is most effectually done by sending them out of town 
during the hot weather whenever the means of their parents will permit 
it, or if they do not, by insisting that they shall spend as much time 
as possible in f ^ open air, and be sent upon short excursions into the 
country. In vn'ition to this, their diet should be carefully regulated, all 
overcrowding evented, and imperfect drainage or ventilation corrected. 
If these precautions are taken, attacks may often be averted. But even 
after the child is actually taken sick it should be removed, if possible, from 
the town, preferaKy to the sea-coast ; sea air under these circumstances 
often exerting a v j'iderful influence for good. If too ill to bear a long , 
journey, or if circj instances fender this impossible, it should be carried to 
the squares or pa,t e •> of the ' T , and allowed to remain there for several I 
hours. I jn-de'^y Vately ill children will often show signs of improvement 
while in J oper ,ir. 

The di .rhoea,'with which the disease is usually ushered in, should never 
be allowed to run on without an attempt being made to check it. Small 
doses of calomel, from T J g to ^ of a grain, according to the age of the pa- 
tient, administered every two or three hours, will often have a happy effect 
in controlling this symptom as Avell as the tendency to vomit. At other 
times, the aromatic syrup of rhubarb, either alone or with chalk mixture, 
will be found to be a useful remedy. Later, chalk mixture and an astrin- 
gent, such as tincture of rhatany, may be given. When collapse has oc- 
curred, it will be necessary to stimulate the patient. This may be done 
by giving a few drops of brandy, either alone, in milk, or in combination 
with sulphuric acid and morphia, but the last-named drug must be given 
in very small doses and with extreme care, as experience has shown 
that it is a dangerous remedy in this disease. Attempts may also be 
made to rouse the cutaneous circulation by the application of mustard I 
plasters to different parts of the surface of the body, especially the abdo- 
men. When the skin is hot and dry, relief is often afforded by cold bath- 
ing or sponging. 

Other remedies are tannic acid, bismuth, pepsin, nitrate of silver, and j 
acetate of lead ; a combination of bismuth and pepsin yielding excellent 
results when the stools contain undigested food. During convalescence, 
tonics should be prescribed, and among them the tincture of the chloride of 
iron may be mentioned as especially useful. 

When there is no vomiting, the child, if it has been weaned, or if a 
wet-nurse cannot be procured, should be allowed milk, either alone, diluted 
with water, or made up with arrowroot, given in small quantities fre- 
quently repeated. If this be rejected, the milk may be given diluted with 
;an equal bulk of lime-water, or, what is in many cases better borne, weak 
chicken-tea may be administered. It will occasionally be found neces- 
sary to have recourse to beef-tea or to Valentine's extract of beef. As 
improvement takes place, the diet may be increased, but this should be 
done very guardedly J 



DISEASES OF THE LIVER. 



675 



Section IV. — DISEASES OF THE LIVER AND PANCREAS. 

I. INTRODUCTORY REMARKS. 
A. Anatomical Relations. 

In investigating hepatic diseases, a careful examination of the hepatic 
region should not be neglected. The healthy liver occupies \he right hypo- 
chondrium, extending across the scrobiculus cordis into tl 1 eft hypochon- 
drium ; and throughout this extent is accurately adapted' io the vault of 
the diaphragm. In the recumbent posture, the lower edge is usually con- 
cealed by the lower margin of the right side of the <~hest, except in the 
upper part of the epigastric region, where s all port;'?°JS of the right and 
left lobes lie uncovered. The position of i edge \ a &ies, however, dur- 
ing respiration — descending somewhat in inspiration, 10 pending again in 
expiration; it descends also to a slight extent when t, 'sn^ittii,. pr upright 
posture is assumed. Moreover, in women who lace t. \Uy, a T > occasion- 
ally in other healthy persons, it may be found as mui.. as i "\ ) or three 
inches below the margins of the ribs. In some cases, on the otoer hand, 
it occupies normally a higher position than usual. The upper limit of the 
liver necessarily corresponds to the position of the diaphragm with which 
it is in contact, and is higher, therefore, on the right than on the left side. 
The upper margin, however, of that area of its upper surface which has 
only the diaphragm and thoracic walls in front of it occupies a lower level, 
corresponds to the lower and outer margin of the right lung, and varies 
with the varying positions of that margin. Adopting Frerichs's estimates, 
it may be assumed that (liable to more or less variation) : in the nipple 
line, the true upper boundary of the liver corresponds to the fifth inter- 
space, the line of separation between the edge of the lung and the liver to 
the sixth rib ; in the axillary line, the former to the seventh interspace, 
the latter to the eighth rib ; and near the vertebral column, the former to 
the tenth interspace, the latter to the eleventh rib. It must be added : 
that all that region to which the liver is immediately subjacent is dull or 
nearly so on percussion ; and that in front and to the left the upper part 
of that region merges in the cardiac area, and below and behind in that of 
the right kidney. General increase in the bulk of the liver is attended 
both with the ascent of the upper margin of the hepatic area into the chest, 
and with the descent of its lower margin into the abdomen — the latter 
being necessarily the more considerable. The lower margin then can 
generally be well distinguished, with all its characteristic peculiarities of 
outline. In some cases it descends into the iliac and hypogastric regions. 
When, however, the enlargement of the liver is irregular, or due to the 
presence of tumors, in some cases its extension is wholly at the expense of 
| the thoracic cavity, and the walls of the lower part of the right side of the 
j chest may be distinctly protruded over it ; in other cases, its extension 
J takes place mainly downwards, and the irregularity of form of the affected 
j organ may then be readily distinguished through the abdominal walls. 
[ ^When the liver diminishes in size its area of dulness shrinks correspond- 
ingly, and sometimes wholly disappears. Occasionally, moreover, under 
I these and other circumstances, the intestines rise up and intervene between 
j the liver and parietes. 



676 



DISEASES OF THE DIGESTIVE ORGANS. 



B. Physiological Considerations. 

In entering upon the subject of the diseases of the liver it is important 
that we should have some preliminary acquaintance with the nature of the 
functions which this organ has to perform, and on the disturbance or 
modification of which many of the more important or striking phenomena 
of hepatic disease necessarily depend. In the brief review of this subject, 
which we are now about to place before the reader, we shall avail ourselves 
largely of the masterly summary given by Dr. Murchison in his work on 
the functional derangements of the liver. 

The liver appears to have at least three important and more or less 
distinct offices to fulfil. First, starchy and saccharine matters, brought to 
it by the portal vessels from the alimentary canal, are converted by it 
into glycogen (C 6 H 10 O 5 ), a substance resembling dextrine, and convertible, 
like it, into sugar "by the action of albuminoid ferments. Glycogen is 
formed and stored' in the hepatic cells, whence (especially during the in- 
tervals of fasting/ i f t is removed in the form of sugar by the hepatic veins, 
and then distribute^ : partly, for the maintenance of heat, to be converted 
by the respired cf\ygen into carbonic acid and water ; partly to take an 
important share in the growth, development, and functional activity of 
cells, and probably even in the development of the white corpuscles of the 
blood. Further, glycogen is probably convertible into fat, and, under 
certain circumstances, the source of accumulation of oil in the hepatic 
cells, or of adipose deposition in other parts of the body. Second, albu- 
minous matters, Avhether derived directly from the food, or constituting an 
essential part of the blood, and especially fibrine, appear to become re- 
duced, through the agency of the liver, into various simpler compounds. 
These include glycogen, the destination of which has already been con- 
sidered, and effete matters, such as leucine (C 6 H 13 N0 2 ) and tyrosine 
(CgH^NOg), which are ultimately resolved into uric acid (C 5 H 4 N 4 0 3 ), and 
more particularly into urea (CH 4 N 2 0), and then discharged with the 
urine. Urea itself appears, at all events to some extent, to be manu- 
factured in the liver. Third, the liver secretes bile. This is a thin, I 
transparent, golden-yellow fluid, which gets viscid and assumes a darker 
color in the gall-bladder in consequence of its admixture with mucus, j 
Roughly speaking, about two pints of bile are secreted daily by a healthy 
adult, of which from 9 to 17 parts per cent, consist of solid matters. These I 
comprise small though varying proportions of mucus, fat, salts, and com- 
pounds due to the disintegration of albuminous substances, but mainly 
certain ingredients of special interest and importance, namely resinous 
acids in combination with soda, coloring matter, and cholesterine. The 
resinous acids, which are two in number, are the glycocholic and the J 
taurocholic ; they are both conjugate acids, the former being formed by 
the union of giycocoll (C 2 H.N0 2 ) with cholic acid (C 24 H 40 O 5 ), the latter 
by the union of giycocoll with taurine (C 2 H 7 N0 3 S). The latter acid con- 
tains all the sulphur of the bile, and to it the bitterness of this fluid is due. 
The peculiar color of bile is owing to the presence of a pigment iioav 
termed bilirubine (C lB H ls N 2 0 3 ). This readily undergoes oxidation even 
in the gall-bladder, becoming successively yellow, green, brown, and 
black. Bilirubine crystallizes in ruby-colored, rhomboidal crystals, which 
are scarcely, if at all, distinguishable from hamiatoidine crystals, but 
chemically are said to contain one atom more of carbon. Cholesterine 
forms a small but constant part of the solid constituents of the bile, and is 



DISEASES OF THE LIVER. 



677 



usually the main constituent of biliary calculi. As regards the sources of 
the essential ingredients of the bile, it has been maintained by some that 
they are, like urea, formed in the blood, and simply separated from it by 
the liver ; by others that they are a product of that disintegrating power 
which the liver itself has over the albuminous and other matters which 
are brought within its influence. The latter view is now generally 
accepted. Taurocholic and glycocholic acids appear, therefore, to be pro- 
ducts of that disintegration of albuminous substances to which reference 
has already been made ; and bilirubine to be a derivative of the coloring 
matter furnished by disintegrating blood-corpuscles. It has been suggested 
by Dr. Austin Flint, Junr., that the cholesterine of the bile is to be traced 
to the disintegration of nervous tissue, and that one of the chief functions 
of the liver is the separation of this fatty matter from the blood. The pur- 
pose and destination of the bile have been equally a matter of dispute. 
There is little doubt, however, that the bile is an important agent in the 
saponification and absorption of fats, and even in the assimilation of albu- 
minous matters, and further, that it promotes peristaltic action, and arrests 
decomposition. It is certain that it is only in some small degree excre- 
mentitious, the great bulk of it, like saliva and gastric juice, being reab- 
sorbed, in a more or less modified condition, into the system. The 
excrementitious parts comprise portions of the coloring matter and of 
cholic acid, and certain derivatives of cholesterine. The parts which are 
reabsorbed comprise the taurine, the glycocoll, the greater part of the 
cholic acid, and a considerable proportion of the coloring matter ; which 
last, there is reason to believe, becomes converted into the pigment of the 
urine. 

C. Pathological Considerations. 

It will be readily understood from the above observations how numerous 
and various are the ways in which diseases of the liver may affect the 
nutritive and other processes of the body, and how numerous and various 
are the symptoms to which they may give rise. Diabetes has long been 
regarded as a functional affection of the liver ; and Dr. Murchison attri- 
butes to functional disturbance of this organ not only gout, renal calculi, 
and biliary calculi, but a large proportion of the functional and structural 
derangements of nearly all the organs and tissues of the body. The most 
striking, if not the most important, results, however, of hepatic diseases 
are those which are connected with derangement or suppression of the 
biliary secretion — namely, jaundice and various associated phenomena, 
which will presently be fully considered. 

A further consequence of structural disease of the liver, or of any dis- 
ease implicating the trunk of the portal vein, is impediment to the ready 
flow of blood through this vessel or through its branches of distribution 
to the liver, and hyperemia of the tributary vessels connected with the 
other chylo-poietic viscera. This hyperemia leads to various mechanical 
consequences, especially to permanent dilatation of the vessels, which when 
occurring in the vicinity of the anus constitutes haemorrhoids ; to more or 
less profuse hemorrhage from the mucous surface of the alimentary canal ; 
and to abdominal dropsy. 

Jaundice — This is due to the circulation with the blood, the deposition 
in various tissues, and the separation, through the agency of certain un- 
wonted emunctories, of the coloring matter of the bile, and its various 



678 



DISEASES OF THE DIGESTIVE ORGANS. 



modifications. But, as we have pointed out, the bile contains other ingre- 
dients beside coloring matter, and the hepatic cells have other functions 
to perform besides the mere manufacture of bile. It is obvious, therefore, 
that the existence of jaundice — the circulation of biliary coloring matter 
— almost necessarily involves the circulation of other ingredients of the 
bile which are less readily detected, and probably also the presence in the 
blood in greater or less abundance of various effete derivatives of albumin- 
ous matters. 

But what is the explanation of the accumulation of biliary coloring 
matter in the blood? By those who hold that the liver excretes biliru- 
bine and the other constituents of the bile exactly as the kidney excretes 
urea, jaundice is attributed to loss or diminution on the part of the liver 
of its dialyzing power. There is ample evidence, however, from the 
results of removal of the liver in the lower animals, that bile is not formed 
in the blood, and that as a general rule the presence of the liver is essen- 
tial to the production of jaundice. It is certain also that when jaundice 
follows the experimental obstruction of the hepatic ducts, it first manifests 
itself in the hepatic cells and then in the lymphatic vessels which take 
their origin in the liver — facts which clearly demonstrate that in this case 
at all events the jaundice is due to the passage into the general circulation 
of coloring matters manufactured in the liver. It has hence been assumed, 
and doubtless with truth, that in those cases in which jaundice is due to 
obstruction, the coloring matter of the bile formed in the cells is absorbed 
both from the cells, and from the hepatic ducts behind the seat of obstruc- 
tion, by the hepatic venous capillaries and lymphatics, and thus becomes 
distributed throughout the system. It has also been assumed, but on a 
far less substantial basis, both by Frerichs and by Murchison, that jaun- 
dice may arise, in cases of prolonged constipation and in cases of exces- 
sive secretion of bile, from absorption taking place at the mucous surface 
of the bowel. 

But if the hepatic cells are in a condition to manufacture bilirubine they 
are doubtless also in a condition to manufacture the biliary acids. What, 
then, becomes of these ? They are absorbed, together with biliary color- 
ing matter, and mingle with the circulation, but what becomes of them 
further is still a matter of dispute. Dr. G. Harley and others assert that 
they accumulate in the blood, and are discharged with the urine, in which 
fluid they may be detected by appropriate means. Frerichs, on the other 
hand, and Dr. Murchison agrees with him, believes not only that they are 
never found in the urine, but that in the blood they speedily undergo 
chemical changes, and their identity becomes lost. Frerichs, it may be 
added, holds that the reabsorbed biliary acids may be converted into biliary 
pigment, and that hence their absorption may increase jaundice if it do 
not absolutely create it. 

But, even if it be admitted that the above explanation holds good of all 
those cases in which jaundice is due to obstruction of the hepatic ducts, 
and that it may be extended to cases of jaundice (if there be such) re- 
ferable to intestinal obstruction, or to excessive production of bile, it is 
clearly inapplicable to some, at all event, of those cases in which (as in 
pysemia and certain infectious fevers) jaundice is an item of a general dis- 
ease, and to the cases in which (as probably in malignant jaundice) the 
icteric tinge is associated with the destruction of the secreting cells of the 
liver, and their consequent inability to discharge their specific functions. 
The close relationship of the coloring matter of the blood to that of the 



DISEASES OF THE LIVER. 



679 



bile, and the facts that the one is derived from the other ; and that both 
yield parallel series of almost indentical colored derivatives, make the 
view which Virchow strongly advocates — namely, that in many of the 
latter cases, jaundice is due, not to the agency of the liver, but to changes 
in the haematine effected in the general circulation — both highly probable 
and easy of acceptance. Frerichs, however, even in reference to some of 
these cases, prefers to believe that the jaundice is attributable to the ab- 
sorption of the elements of bile at the mucous surface of the bowel and 
to interference with the due course of those changes which the reabsorbed 
bile should undergo in the blood. 1 It is important to add : that when, as 
in malignant jaundice, the secreting structure of the liver is destroyed, 
the jaundice is not usually intense, and the biliary acids are certainly never 
detected in the urine, while on the other hand, the retrograde metamor- 
phosis of albuminous matters remains incomplete, and leucine and tyrosine, 
which accumulate in the blood, replace more or less completely urea in 
the urine : and that, according to Dr. G. Harley, Kiihne, and others, when 
jaundice is the result of obstruction, the biliary acids may be recognized 
in the urine, and that their recognition there may be taken as a proof of 
the obstructive origin of the jaundice. 

The phenomena which attend and indicate jaundice, and the conse- 
quences which flow from it are very various, but the more important of 
them may be readily enumerated. 

1. There is usually deficiency of bile in the alvine discharges, and more 
or less consequent tendency to constipation, flatulence, fetor of the evacua- 
tions, faulty assimilation, especially of fat, and distaste for fat. If the bile 
be wholly absent, these phenomena are more strongly marked, and the 
feces acquire a chalky, gray, or slaty color, or assume some tint referable 
to the prevailing character of the patient's diet. Diarrhoea sometimes 
comes on ; and fatty matters, but little altered, are apt to pass away with 
the evacuations. 

2. Omitting for the present all reference to the changes taking place in 
the liver itself, the coloring matter of the bile first accumulates in the blood, 
then escapes with the urine, and subsequently gradually tinges the con- 
junctivae and skin, passing off at the same time in some small degree with 
the sweat. Other parts which become bile-stained are the serous mem- 
branes and all effusions which take place in connection with them, the 
connective and fibrous tissues, fat, muscles, and bones. The mucous mem- 
branes as a rule are scarcely affected ; and the secretions from their sur- 
faces and from the glands which open upon them are usually entirely free. 
The brain and nerves remain for the most part uncolored. The only se- 
cretions besides those of the kidneys and sudoriparous glands, which have 

[ ! Frerichs's theory may be briefly stated as follows : The biliary acids are in 
part directly absorbed into the blood either by the hepatic vein or by the veins of 
the intestines, and are in health converted through oxidation into taurin and the 
urinary coloring matter. In some forms of disease, however, these acids are in- 
completely oxidized, and are then changed into bile-pigment. Dr. Murchison 
teaches, on the other band, that absorption of the bile-pigment as well as of the 
acids is all the time going on in the intestines ; but that under normal circum- 
stances its accumulation in the blood in such quantities as to cause discoloration 
of the skin is prevented by its transformation into other substances. If this 
metamorphosis be interfered with from any cause, jaundice will occur. In this 
way he explains the icterus which follows the introduction of certain poisons into 
the blood, or that which appears in the course of some of the fevers, or as the result 
of nervous influences, such as fear, passion, and the like.] 



680 



DISEASES OF THE DIGESTIVE ORGANS. 



certainly been found to contain bile, are that of the mammary gland and 
those furnished by inflamed mucous surfaces. Superficial jaundice first 
shows itself in the conjunctivae, but soon becomes generally diffused through- 
out the whole cutaneous surface. It is at first a mere condition of sallow- 
ness, but soon assumes a saffron or golden yellow hue, and if long continued, 
a brownish, olive, or bronze-like tint. The seat of discoloration is mainly 
the rete mucosum and the sudoriparous glands. The secretion of the lat- 
ter, indeed, sometimes becomes so largely charged with bile-pigment as to 
stain the linen. The usual characteristics of bilious urine, and the tests 
for the recognition of bile-pigment in that fluid, are elsewhere considered. 
It may, however, be pointed out here that the urine varies in color 
from a saffron-yellow to a greenish or brownish black, that its froth always 
presents a peculiarly yellow hue, that it stains white paper and linen, and, 
further, that it is generally free from sediment, transparent, and acid. It 
is apt, however, to present other peculiarities, of which some have been 
already adverted to ; it commonly yields uratic or other deposits ; it may 
possibly, when the jaundice is obstructive, contain bile acids ; it certainly 
displays, in the presence of extensive destruction of the hepatic cells, a re- 
markable diminution of urea and of phosphates, and in their place a great 
abundance of leucine and tyrosine, which then sometimes fall as a greenish- 
yellow sediment ; and, lastly, there is often, especially towards the fatal 
close, either glycosuria or albuminuria, or both. Albuminuria is probably 
connected with the irritation caused by the long-continued passage of bile- 
pigment. All the tissues of the kidneys, and more especially the cells of 
the convoluted and straight tubes, gradually get deeply stained ; and the 
canals of the tubes are not unfrequently occupied by granular or amorphous 
pigmented casts, which become shed and may be found in the urine. 

3. There are a number of other phenomena occasionally associated with 
jaundice, of which some are interesting, others are of grave importance. 
It is asserted that sometimes all objects appear yellow to jaundiced patients. 
But this occurrence is rare, and the explanations which have been given 
of it are conflicting. There is often troublesome, and sometimes unbear- 
able, itching of the skin. This is not generally attended with obvious 
eruption ; but occasionally we find lichen, urticaria, or some one of the dif- 
ferent varieties of erythema multiforme. Vitiligoidea or xanthoma is well 
known to be frequently associated with chronic jaundice. The action of 
the heart is usually much enfeebled, and often reduced in frequency ; there 
is also a marked tendency to the occurrence of hemorrhage, revealing itself 
by the appearance of petechias, or by epistaxis or gastro-intestinal or other 
fluxes, which may be so copious, or so frequently repeated, as to prove 
fatal. Together with these symptoms the patient usually becomes emaciated 
and feeble, irritable or low-spirited, and little capable of resisting the in- 
fluence of either mental or bodily fatigue or changes of weather. 

It is not surprising that patients suffering from jaundice should sooner 
or later present impairment of nutrition and other indications of profound 
ill-health. It is surprising rather that they should live as long as they 
occasionally do, and yet present so few symptoms and undergo so little 
suffering ; and that bile itself should, as has been shown by experiment, 
have so little injurious influence over the blood and the various corporeal 
functions. Occasionally, however, symptoms of so-called ' bilious toxaemia' 
arise. They seem, however, to occur mainly, if not solely, in those cases 
in which jaundice is connected with destruction of the hepatic cells, in 
which urea tends to disappear from the urine, and leucine, tyrosine, and 



INFLAMMATION OF THE HEPATIC DUCTS. 



681 



other products of albuminous decomposition circulate with the blood and 
find their way into the urine. And, indeed, the toxsemic effects seem to 
be due, not to the influence of the proper elements of bile, but to that of 
various excrementitious matters, of which leucine and tyrosine are prob- 
ably the most important. The symptoms here referred to comprise : in 
the first instance, headache, restlessness, mental depression or excitement, 
and sense of illness; then busy or violent delirium, or convulsions, vary- 
ing from mere rigors to general epileptiform attacks or tetanic spasms, or 
delirium and convulsions intermingled ; and finally stupor, passing into 
coma and death. 



II. INFLAMMATION OF THE HEPATIC DUCTS. 

Causation Inflammation of the biliary ducts and of the gall-bladder 

may be due to the presence of gravel or calculi, or to the extension of 
inflammation from the parenchyma of the liver. These subjects will be 
considered hereafter. But inflammation affecting mainly the mucous sur- 
face, and catarrhal in character, frequently arises from exposure to vicis- 
situdes of weather, or gastro-intestinal disturbance, and perhaps also in 
connection with pneumonic and other acute inflammations, and various 
infectious fevers. It is most frequently preceded by similar affection of 
the duodenum. 

Morbid anatomy Catarrhal inflammation is generally indicated by an 

excessive discharge of ropy mucus, and by a swollen condition of the mu- 
cous membrane ; and these phenomena not unfrequently lead to more or 
less complete obstruction. This usually occurs in the common duct, and 
especially in that part of it which is embraced by the intestinal walls. It 
is generally temporary, subsiding in the course of two or three weeks or 
less, but sometimes results in organic stricture, sometimes in permanent 
closure, or in closure which is relieved only by the supervention of more 
or less extensive ulcerative destruction. In some instances a false mem- 
brane forms upon the mucous surface, and occasionally polypi or papillary 
growths are developed. The most remarkable consequences of catarrhal 
inflammation are those which are dependent immediately on mechanical 
impediment to the escape of bile, and which therefore are associated from 
the beginning with mechanical distension of the ducts. These are suppu- 
ration, hemorrhage, ulceration, and more or less extensive destruction of 
the mucous membrane. 

Symptoms and progress — The early symptoms of catarrhal inflammation 
of the gall-ducts, which are usually undistinguishable from those of the 
gastro-intestinal catarrh with which they are associated, are mainly flatu- 
lence, distension, weight and pain in the region of the stomach, nausea 
and vomiting, and for the most part constipation, together with slight 
febrile disturbance. The proof of implication of the hepatic ducts is fur- 
nished after the affection has lasted for several days, possibly a week or 
two, by the supervention of jaundice with some degree of tenderness and 
enlargement of the liver. In many cases the symptoms preliminary to 
jaundice are so vague and slightly developed that they escape observation ; 
and not unfrequently they subside shortly after the supervention of jaun- 
dice. The jaundice itself, however, with constipation and other results of 
retention of bile, usually continues for a week or two, or a little longer. 



G82 DISEASES OF THE DIGESTIVE ORGANS. 



Catarrhal inflammation almost always ends in resolution within the period 
above assigned. Sometimes, however, it becomes chronic, and may then 
continue for months with the combined symptoms of gastro-intestinal irri- 
tation and retention of bile, the patient probably becoming feeble and 
emaciated. The consequences of permanent stricture, or of complete 
impediment to the escape of bile, will be considered under the head of 
4 Obstruction of the hepatic ducts.' 

Treatment — In treating the affection under consideration, febrifuge or 
alkaline medicines, and saline purgatives, or mild laxatives of other kinds 
are generally indicated. Food of an unstimulating character, for the most 
part farinaceous substances and milk, should be administered. And local 
pains or uneasiness, should be counteracted by hot fomentations or counter- 
irritants. Leeches or cupping is rarely if ever necessary. It is often well 
to have Recourse to those remedies which have a special influence over the 
morbid conditions of the gastro-intestinal mucous membrane, and espe- 
cially to stomachic combinations, such as mixtures of soda, potash, or bis- 
muth with rhubarb, ginger, and some bitter infusion. Emetics also have 
been strongly recommended in the early stages of the disease, with the 
object mainly of promoting the flow of bile along the obstructed tubes, or 
of effecting the dislodgment of the plugs of mucus which it is assumed 
may be impacted in them. 



III. ACUTE HEPATITIS. ABSCESS OF THE LIVER. 

Causation Acute inflammation arises under various circumstances. It 

may be due to injury ; to the irritation of adventitious growths or hydatids ; 
to extension of inflammation from the ducts or veins or from without ; to 
pyaemia, whether taking its origin in ulceration of the bowel or from some 
more remote source ; to pre-existing congestion of the organ, especially in 
connection with heart disease ; to the influence of acute inflammations, 
such as erysipelas and pneumonia, or of the specific fevers, such as yellow 
fever, smallpox, and scarlatina ; to the toxic effects of phosphorus and 
certain metallic poisons ; and lastly, it is not unfrequently of idiopathic 
origin, mainly, however, in tropical climates and in connection with dys- 
entery. The nature of the relation between dysentery and hepatic abscess 
has already been discussed under the head of ' Dysentery.' 

Morbid anatomy Inflammation of the liver, as of other organs, affects 

mainly the connective tissue and the small vessels in the meshes of, which 
the proper elements of the gland are contained. The vessels become 
dilated and full of blood with a superabundance of leucocytes ; the tissues 
get infiltrated with inflammatory exudation ; and a development of em- 
bryonic tissue takes place in the walls of the small vessels and ducts, and 
their immediate vicinity, in Glisson's capsule, and generally in the con- 
nective tissue. At the same time the proper cells of the liver become 
swollen and cloudy and even the seat of fatty or pigmental deposition, and 
are sometimes destroyed. The appearances presented by the inflamed 
tissues differ widely in different cases, in dependence mainly on the causes 
to which the inflammation is due and on its intensity. In some cases the 
most - marked features are uniform opacity and lightness of tint, with 
doughiness of consistence, and enlargement of the lobules. These pecu- 



ACUTE HEPATITIS. ABSCESS OF THE LIVER. 



683 



liarities are due to the fact that the hepatic cells have become cloudy and 
swollen ; while, in some measure owing to this very circumstance, there 
is but little inflammatory exudation present, and the vessels contain little 
blood. When a limited portion of liver is thus affected, the pallid and 
swollen patch is usually surrounded by a more or less diffused area of con- 
gestion ; when the whole organ is implicated, the pallor may be uni- 
versal, or it may be marbled with patches of congestion. As will here- 
after be shown, there is reason to believe that the condition known as 
yellow atrophy of the liver is probably an inflammation of the kind here 
referred to. 

Inflammation ending in abscess is probably always circumscribed and at 
the same time necessarily intense. The early stage of suppuration is 
usually indicated by pallor, opacity, and swelling of a definite patch of 
liver substance, the tissues immediately surrounding which and for some 
distance beyond are generally more or less deeply congested. Soon the 
affected patch softens, and then breaks down. The process is identical 
with that of the formation of abscesses elsewhere : embryonic cells make 
their appearance in large numbers, the hepatic cells become swollen, 
granular, fatty, and fall into detritus, and the web of connective tissue in 
which they are imbedded liquefies and disappears under the influence of 
the inflammatory exudation and growth. If the abscess extend, these 
processes gradually involve the surrounding structures, partly by simple 
extension, partly by the development of new foci in the immediate 
vicinity. And, under such circumstances, it not unfrequently happens 
that abundant shreds and filaments of a pinkish-gray hue and soft con- 
sistence hang from the parietes of the abscess into its cavity, and that 
these if traced outwards are found to merge into a pulpy flocculent net- 
work, infiltrated more or less abundantly with pus, and from the meshes of 
which the disintegrated liver-cells have disappeared. The purulent con- 
tents vary in character, and are not unfrequently tinged with bile ; they 
are often glairy and of a greenish hue. Hepatic abscesses vary in their 
seat, size, and number. They may be found in any part of the liver. 
They may range from the size of a pin's head up to that of a cocoa-nut, 
and, indeed, are sometimes much larger than this. In the Netley Museum 
(according to Dr. Maclean) is an hepatic abscess which contained no less 
than seventeen pints of pus. They may be solitary, or may amount 
numerically to 20, 30, or even 100. Idiopathic abscesses are for the most 
part solitary, or at any rate occur in small numbers. When they are 
numerous there is reason to suspect a pyasmic origin. It is important, 
however, not to overlook the remarkable influence which the various 
tubes permeating the liver exert over the distribution and multiplication 
of abscesses. Pus or inflammatory lymph gaining entrance into the portal 
veins may be conveyed in the form of emboli until they become arrested 
in vessels too small for their further transit ; when as a result congestion, 
followed by softening and suppuration, of the arese to which the obstructed 
vessels lead takes place. This condition not unfrequently ensues upon a 
spreading hepatic abscess : a branch of the portal vein in the substance of 
the liver becomes involved ; pus in more or less abundance enters the 
affected vessel and is thence distributed amongst its ramifications, causing, 
sometimes the formation of scattered abscesses in some particular district, 
sometimes a series of branching abscesses due to the conversion of the 
veins themselves into suppurating channels. The same thing may occur 
in connection with the hepatic vein ; some large branch of which may get 



684 



DISEASES OF THE DIGESTIVE ORGANS. 



perforated by an advancing abscess ; when, communication with the cava 
having been cut off by the formation of a plug, the pus may flow back- 
wards into the tributary branches, and a ramifying abscess result. Again, 
one of the hepatic ducts may be the seat of a like mischance. It may 
become perforated by an hepatic abscess which may then discharge itself 
into the bowel ; or, the duct becoming obstructed below the seat of per- 
foration, the pus may be driven back into the smaller branches. More- 
over, inflammation, commencing in the biliary ducts, sometimes leads to 
abundant suppuration, and occasionally to the almost complete destruction 
of their parietes and the development of irregular branching abscesses. 
Some of the terminations of hepatic abscesses have been indicated in the 
foregoing statement. It remains to add that they may discharge them- 
selves in various directions ; as, for example, through the external 
abdominal parietes ; through the diaphragm into the pericardium, pleura, 
or lung ; or into the peritoneum, stomach, duodenum, or colon. Some- 
times the abscess burrows, and it may then take almost any route : either 
infiltrating the tissue of the great omentum ; or running downwards in the 
meso-colon or behind the peritoneum and thus finding its way into the 
caecum or rectum, bladder or vagina, or taking either of the courses which 
an ordinary psoas abscess is apt to take. In some instances the abscess 
ceases to spread, the tissues around get thickened and indurated, and the 
matter becomes encysted, and undergoes fatty, caseous, or calcareous 
change. 

Symptoms and progress — The symptoms which attend inflammation of 
the liver are exceedingly various and often so slight as to elude observa- 
tion. They include enlargement of the organ, which may be detected by 
inspection, palpation, and percussion; weight, and uneasiness or pain in 
the hepatic region, which last is often increased, and perhaps only devel- 
oped by pressure, change of position, or the respiratory acts ; occasional 
sympathetic pains in the right shoulder, and possibly down the right arm ; 
disturbance of the digestive organs, indicated by fulness, flatulence, nausea, 
sickness, and loss of appetite ; and slight febrile disturbance. Jaundice 
not unfrequently supervenes, but is rarely intense. It must be added that 
the pain is always most severe when the surface of the liver is involved ; 
that it is then of a pricking or cutting character, resembling that of ordi- 
nary acute peritonitis ; and that it is in this case chiefly that the move- 
ments of respiration become affected, as in diaphragmatic pleurisy, that 
the sympathetic pain in the shoulder manifests itself, and that a dry hack- 
ing cough is induced. 

The symptoms of hepatic suppuration are in many cases vague and 
misleading. This is no doubt due in part to the fact that hepatic abscess 
so often supervenes in the course of dysentery or pyaemia — affections 
which by the severity of their proper symptoms tend to overshadow those 
of the hepatic complication. It is not, however, due entirely to this 
cause; for idiopathic suppuration, independent of dysentery, and the sup- 
puration which complicates hydatid tumors, not unfrequently (for a time 
at least) fail of recognition. The local indications of abscess are pain and 
tenderness in the region of the liver, tumor in the same situation, dis- 
placement of neighboring organs, and interference with their functions. 
Pain and tenderness may be almost entirely absent ; and when present 
they vary largely in intensity and extent. They are generally most severe 
when the abscess approaches the surface and this becomes implicated. 
The pain is then, as in peritonitis, of a pricking or cutting character. 



ACUTE HEPATITIS. 



ABSCESS OF THE LIVER. 



685 



When the abscess is deep-seated, it is usually dull and aching. Pain re- 
ferred to the right shoulder is not unfrequent during the progress of sup- 
puration. Whether or not there be any obvious enlargement of the liver 
depends partly on the number, partly on the size, partly on the situation 
of the abscesses. An abscess, even of large dimensions, situated at the 
back, or deeply imbedded, may easily escape observation. It may, indeed, 
lead to the descent of the anterior edge of the liver, and so induce a belief 
in the uniform enlargement of the organ, which is of course no sufficient 
indication of the presence of an abscess. When, however, the abscess is 
situated more anteriorly, it tends gradually to form a rounded mass, which 
increases more or less rapidly in size, protrudes the parietes, and sooner or 
later probably yields a distinct sense of fluctuation. This protrusion 
sometimes occupies the scrobiculus, and may then involve also more or 
less of the umbilical and hypochondriac regions; sometimes it takes place 
principally upwards, displacing the lungs and heart; not unfrequently it 
occurs mainly towards the right side of the chest, in which case the base 
of the lung may be displaced upwards considerably above the level of the 
nipple, and the corresponding part of the thoracic walls, with more or less 
of the adjoining hypochondrium, may form a smooth round swelling. It 
is always important in these cases to determine the exact limits of the 
hepatic mass 1 and of the area of dulness. As regards neighboring organs, 
the diaphragm is not only frequently displaced, but from the implication 
of the convex surface of the liver is often embarrassed in its action, and 
respiration becomes thoracic, shallow, and painful, and a dry hacking 
cough and hiccough arise; the stomach, again, is often displaced, and 
nausea, vomiting, and other dyspeptic symptoms may consequently ensue. 
The general symptoms due to hepatic abscess are various. The most im- 
portant probably are those of fever. Fever, however, is sometimes wholly 
absent, and may indeed be absent during the entire progress of cases 
attended with extensive suppuration. More commonly, however, there is 
some elevation of temperature, either at the commencement of suppura- 
tion, or at some intermediate period of its progress, or at a late stage 
when the surface of the liver becomes involved, or during the whole course 
of the case. The temperature does not commonly rise above 102° or 103°, 
presents for the most part morning remissions and evening exacerbations, 
and is sometimes attended with chills or even severe rigors, which in their 
severity and periodicity may simulate those of ague. The fever, if persistent, 
assumes a hectic character, and is attended with profuse perspiration, 
especially at night time. Jaundice is by no means a necessary accompa- 
niment of hepatic abscess. It is occasionally present, however, and is 
then usually slight. The condition of the digestive organs varies con- 
siderably. Sometimes they are but little affected; sometimes, on the 
other hand, the tongue may be coated or dry, and thirst, loss of appetite, 
flatulence, nausea, vomiting, diarrhoea, and other indications of gastro- 
intestinal irritation or catarrh, may be developed. 

Hepatic abscess is always an affection of great danger, and frequently 
proves fatal. In some cases death is due simply to the impairment of 
nutrition and the extreme debility which extensive suppuration entails. 
Sometimes these conditions are associated with the persistence of a febrile 
temperature, or with the retention of effete matters in the blood ; and the 
patient, previous to death, lapses into a typhoid state, with dry brown or 
black tongue, subsultus tendinum, and muttering delirium. In a large 
number of cases, however, complications ensue, dependent mainly on the 



686 



DISEASES OF THE DIGESTIVE ORGANS. 



bursting of the abscess into, or the extension of inflammation to, some 
neighboring organ. The nature of these has already been sufficiently 
considered under the head of morbid anatomy. For their symptoms we 
must refer to the accounts of the diseases of the several organs which may 
be thus implicated. When restoration to health occurs it may be due 
either to the abscess becoming encysted and undergoing degeneration, or 
to the discharge of its contents through the abdominal walls, or lung, or 
into the bowel. 

Treatment — The treatment of hepatic inflammation must depend on 
the nature and severity of the symptoms by which it is attended. Febri- 
fuge or alkaline medicines, and saline purgatives or mild laxatives of other 
kinds, are generally indicated. Food of unstimulating character, for the 
most part farinaceous substances and milk, should be administered. And 
local pains or uneasiness should be counteracted by hot fomentations or 
cold applications, or by counter-irritants, such as mustard plasters and the 
like ; or if there be much feverishness, and the local phenomena be at the 
same time severe, by the use of leeches or the cupping-glasses. Amongst 
drugs which are frequently had recourse to in the treatment of these affec- 
tions (especially when they are severe or chronic in character), and which 
are for the most part highly esteemed, are iodide of potassium, chloride of 
ammonium, taraxacum, and nitro-muriatic acid. During convalescence 
good diet, change of air, and tonics are always valuable. 

In the earlier stages of hepatic suppuration, nothing probably arises to 
call for special treatment. When, however, the abscess is so far devel- 
oped as to render its presence pretty certain, the question of evacuating 
its contents arises. It is a moot point whether it should be allowed to 
take its own course, to open when and where it pleases, or whether it 
should be punctured at the earliest possible opportunity. Dr. G. Budd is 
a strong advocate of the former plan. Many, however, prefer the latter 
procedure, and we are of their number. The risks, indeed, which attend 
the progress of an abscess are, partly from the amount of disorganization 
it produces in the liver itself, partly from the uncertainty as to the route 
it may take, so serious, that they can scarcely be aggravated by operative 
procedure and they may be largely diminished by it. We believe the best 
plan is to evacuate the contents as soon as opportunity offers, by means of 
a fine trocar and canula with or without the aid of the aspirator. This 
operation may generally be safely effected even if no adhesions have 
formed between the liver and the abdominal walls. It is well to avoid the 
admission of air, and to employ an evenly and firmly applied bandage 
afterwards. The operation may be repeated from time to time. If the 
discharge become offensive, and adhesions have formed, a free opening 
should be made and maintained; and the cavity of the abscess should be 
occasionally washed out with weak solutions of some antiseptic, such as 
chlorinated soda, nitric acid, carbolic acid, or quinine. During the 
progress of these cases the patient's strength should be supported by 
tonics, stimulants, and nutritious diet. Opiates are always of great value. 
It may of course be necessary to treat gastric and other complicating 
disorders. 



CIRRHOSIS OF THE LIVER. 



687 



IV. CIRRHOSIS OF THE LIVER. 

A. Atrophic Cirrhosis. (Hobnailed or Drunkard' 's Liver.) 

Causation Atrophic cirrhosis is almost always a consequence of the 

persistent excessive use of alcoholic beverages. This, however, is not the 
sole cause of the disease. For it is occasionally met with in persons who 
have been undoubtedly temperate in their habits, and in children who 
have never taken stimulants. It is probably more common in men than 
in women ; and is generally first recognized in persons above 35. 

Morbid anatomy In typical cases the liver is much reduced in size, 

rounded, studded with hemispherical elevations for about J to ^ inch in 
diameter, and obtusely marginated. Moreover generally its capsule is 
thickened and old adhesions bind it to the diaphragm and neighboring 
organs. On section it is found to be remarkably indurated ; and the same 
nodulated condition which marks the surface is manifest throughout its 
substance. This nodulation is due to the permeation of the liver by a 
network of dense grayish fibroid tissue, within the meshes of which the 
proper parenchyma of the organ is contained in the form of roundish 
bodies, varying roughly from the size of a tare to that of a large pea. 
The fibroid growth occupies mainly the capsule of Glisson surrounding the 
small branches of the portal vein, and the vaginal veins, which give rise 
to the interlobular plexuses, and extends thence in a greater or less degree 
into the interlobular spaces. On close inspection it will generally be seen : 
that the larger hepatic nodules are made up of smaller ones — the latter 
comprising several hepatic lobules ; and, moreover, that there is always a 
more or less definite line of demarcation between the annular bands of 
fibroid tissue and the groups of hepatic lobules which they circumscribe. 
The proper hepatic tissue of the hobnailed liver may present its normal 
hue ; but not unfrequently it is fatty and jaundiced and has a light or 
orange yellow tint — whence the name ' cirrhosis.' There is reason to be- 
lieve that in the early stage of the disease the liver is somewhat enlarged, 
and at the same time smooth on the surface. Atrophic cirrhosis appears 
to originate in a chronic inflammatory condition of the branches of the 
portal vein above indicated, attended with the abundant appearance in the 
tissues immediately surrounding them of embryonic cells, which undergo 
slow conversion into cicatricial fibroid tissue, and then gradually contract. 
The inflammatory process rarely implicates the substance of the hepatic 
lobules even at their periphery ; but by the compression to which they are 
subjected the liver cells become flattened and atrophied, and after a while 
disappear to a greater or less extent. It is an interesting fact, in connec- 
tion with the morbid anatomy of the disease, that the adventitious fibroid 
growth (notwithstanding that by involving the smaller branches of the 
portal vein it interposes a serious obstacle to the portal circulation) is itself, 
unlike ordinary cicatricial tissue, richly permeated with large tortuous 
vessels of capillary character. These, though still communicating in some 
degree with the portal system, seem specially to serve as a route for the 
passage of the blood of the hepatic artery to the intralobular vessels ; and 
it is probably in consequence of their presence or development, that the 
nutrition of the liver and the formation of bile are usually maintained to 
the last. Further, as the smaller biliary ducts are not necessarily impli- 
cated, bile is not as a rule retained, and jaundice rarely occurs. The ob- 



688 



DISEASES OF THE DIGESTIVE ORGANS. 



struction of the portal veins leads to hyperemia and distension of the 
tributary vessels, and consequently to dropsy, hemorrhage, enlargement of 
the spleen, development of hemorrhoids, and vicarious dilatation of veins 
— more especially of those about the umbilicus and in the abdominal wails 
above the umbilicus. 

Symptoms and progress Atrophic cirrhosis is for the most part very 

insidious in its progress. In many cases no symptoms manifest themselves, 
sufficient at any rate to attract attention, until the affection is far advanced ; 
in many, the patient suffers only from the usual symptoms of dyspepsia or 
chronic gastric catarrh — symptoms which may equally occur in the absence 
of hepatic disease ; in many, he has vague indications of ill-health with 
progressive loss of strength and emaciation, and these phenomena may be 
associated with distinct evidence of similar disease going on in the kid- 
neys ; in some, no doubt, slight signs of hepatic derangement show them- 
selves from time to time, and, in association with the habits or history of 
the patient, reveal to the careful observer the momentous changes which 
are going on within. The hobnailed liver, excepting perhaps in its earlier 
stages, is usually atrophic, and the normal hepatic dulness is consequently 
diminished in area or suppressed; but the presence of an enlarged liver by 
no means forbids the diagnosis of this disease. Its chief indications are 
the supervention of abdominal dropsy, and the occurrence of hemorrhage 
(often profuse) from the stomach and bowels. The more frequent of these 
is no doubt ascites, but it does not necessarily become developed even in 
fatal cases ; and even when once it has appeared, will sometimes subside 
under appropriate treatment, and never recur. Hgematemesis and melsena 
are sometimes the first indications of the presence of the hepatic disease ; 
and the first attack may prove fatal. When once such hemorrhage has 
occurred, it has a marked tendency to recur ; and it is a phenomenon of 
very fatal augury. Jaundice supervenes in a minority of cases, and is 
very rarely intense. Besides the symptoms just enumerated, others of 
more or less importance are commonly present : There is usually pro- 
gressive and finally extreme emaciation, with a sallow or earthy cachectic 
aspect. There is generally more or less obvious disturbance of the digestive 
functions ; the tongue becomes coated or dryish, and there may be thirst, 
loss of appetite, sense of flatulent distension, nausea and vomiting , the 
bowels may be constipated or relaxed, and, indeed, diarrhoea, which is apt 
to assume a dysenteric character, is not an unfrequent precursor of death ; 
piles are of common occurrence. The urine is often scanty and loaded 
w r ith lithates. And there is a liability for hemorrhage to take place from 
the various mucous membranes and beneath the skin. The tendency of 
cirrhosis is always to a fatal issue, but the duration of the disease is almost 
impossible to ascertain. It may certainly last for many years ; but when 
once distinctive symptoms have shown themselves, the patient's days are 
numbered. He may, however, even then survive for a year or two. The 
immediate causes of death are various. The natural termination is by 
gradual asthenia. But the patient is often carried off by the consequences 
of the ascitic accumulation, by gastro-intestinal hemorrhage, by profuse 
alvine discharges, or by the supervention of pneumonia or other pulmonary 
complications. Not unfrequently also the hepatic affection is only one of 
a series of lesions of an allied character involving, it may be, heart, lungs, 
spleen, kidneys, and other organs. 



CIRRHOSIS OF THE LIVER. 



689 



B. Hypertrophic Cirrhosis. 1 

Causation and morbid anatomy This is a form of cirrhosis which has 

long been recognized and, so far as its coarser features are concerned, 
described by pathologists. But it has only recently been distinguished 
from the ordinary hobnailed liver as a condition having a different pa- 
thology and different consequences. The causes of hypertrophic cirrhosis 
have not been clearly established; but at any rate there is no distinct evi- 
dence that it has any connection with alcoholic intemperance. In this 
condition the liver is enlarged, sometimes to twice or even thrice its normal 
size ; is tolerably smooth on the surface ; and retains its normal form and 
its sharp well-defined anterior edge. It is extremely dense in texture, 
and on section is found to be largely infiltrated with dense grayish slightly 
translucent connective tissue. This does not form a distinct network as 
in the hobnailed liver, circumscribing definite groups of hepatic lobules, 
but is rather a diffused growth in which the remnants of the hepatic pa- 
renchyma are scattered irregularly in yellowish masses from the size of a 
poppy seed to that of a pea. In some parts the hepatic tissue predominates 
and there is an approach to the hobnailed condition ; in some almost every 
remnant of the natural structure has disappeared, and dense fibroid tissue 
alone remains. The remnants of hepatic parenchyma vary in color from 
orange-yellow to green. Microscopically the fibroid growth shows the 
same characters as those of ordinary cirrhosis ; and in its early stage and 
when it is in progress of extension it consists mainly of embryonic cells. 
But it commences, not from the terminal branches of the portal vein, but 
from the interlobular branches' of the bile-ducts, and from those branches 
of them which occupy the periphery of the lobules. The morbid process 
begins in fact with the development of embryonic tissue immediately around 
these channels, whence it spreads — implicating the portal vessels at an 
advanced peried only. It tends also to involve the lobules themselves, 
.which as a rule escape in atrophic cirrhosis. The affected ducts become 
largely dilated and their epithelium increases in quantity. The smaller 
branches, indeed, get blocked up with their accumulated contents. The 
liver cells are atrophied, contain biliary pigment, and are more or less fatty. 
It is important to note that in this disease the obstruction which the fibroid 
growth causes is chiefly of the ducts, and that the portal circulation is not 
necessarily implicated. 

Symptoms and progress — Hypertrophic cirrhosis is a disease mainly of 
adult life, and, like the atrophic variety, is of slow progress. The ordi- 
nary symptoms of derangement of the gastro-intestinal organs, gradual 
emaciation, and failing strength, belong to both affections. But, whereas 
the main consequences of hobnailed liver are ascites and gastro-intestinal 
hemorrhage dependent on obstruction to the portal system ; in this case, 
these phenomena are, for the most part, conspicuous by their absence, and 
dropsy, if it occurs at all, comes on late, and then probably only in a slight 
degree. On the other hand, jaundice, which is generally absent, and never 
well developed in atrophic cirrhosis, always appears early in this disease, 
acquires considerable density, and persists during its whole course. It is 
liable, however, to fluctuations. It need scarcely be added that with the 
jaundice we have all the characteristic phenomena which attend and fol- 

1 Hanot, 'Etude sur une forme de cirrliose hypertrophique de foie.' These de 
Paris, 1876. Charcot. ' Lecons sur les Maladies du Foie, &c.' Paris, 1877. 
44 



690 DISEASES OF THE DIGESTIVE ORGANS. 

low the presence of bile in the blood ; and that consequently such patients 
are specially liable to cerebral and other toxaemic symptoms. The detec- 
tion by palpation of an hypertrophied, hard, and sharp-edged liver is an 
important element in the diagnosis of these cases. The spleen is usually 
hypertrophied. But the superficial abdominal veins are probably not 
enlarged. 

C. Other Conditions allied to Cirrhosis. 

Causation and morbid anatomy Among these we may enumerate — 

the diffused form of cirrhosis observed mainly in syphilitic children ; chro- 
nic inflammatory conditions involving especially the capsule of Glisson 
surrounding the larger vessels and ducts ; and chronic perihepatitis attended 
with compression and atrophy of the liver. 

1. The cirrhotic condition of liver, which occasionally arises in the 
course of syphilis, whether in the adult or in infants, and which is not un- 
frequently associated with the formation of gummata, is characterized (see 
Cornil and Eanvier), as is hypertrophic cirrhosis, by uniform enlargement 
of the organ ; but the enlargement is due to the general development of 
embryonic tissue — not simply in the interlobular spaces, but in the lobules 
themselves, between the columnar groups of cells, and even separating the 
individual cells from one another. In this affection the liver is at first 
readily lacerable, but as the embryonic tissue becomes converted into 
fibrous tissue, the organ becomes indurated ; and its general condition pre- 
sents a close resemblance to that of hypertrophic cirrhosis. 2. It not un- 
frequently happens, sometimes in the course of syphilis, sometimes in con- 
nection with obstructive affections of the ducts, but often under conditions 
which are not understood, that growth of fibroid tissue takes place along 
the vessels and ducts which enter at the transverse fissure. This condition 
is sometimes general, sometimes limited to certain regions ; and may have 
the effect of causing more or less obstruction of the ducts or portal veins 
or both ; and frequently leads to the formation of deep fissures on the sur- 
face of the liver, and to a lobulated condition of that organ. 3. Perihe- 
patitis may occur as a part of general peritonitis ; and generally takes 
place, in a greater or less degree, in connection with the different varieties 
of cirrhosis. Sometimes the fibroid investment is exceedingly thick and 
dense ; and by its contraction compresses the liver into a roundish mass, 
with obtuse ill-defined edges. This sometimes occurs when the general 
texture of the liver is healthy, but necessarily causes more or less com- 
pression, atrophy, and obstruction of vessels and ducts. 

Symptoms and progress It would be difficult to define the symptoms 

and consequences of these several conditions. It is sufficient to say that 
besides inducing, like hobnailed liver, general symptoms of ill-health, they 
are likely, in various degrees, to be attended, sooner or later, with the spe- 
cific consequences of obstructive hepatic disease, namely, ascites, gastro- 
intestinal hemorrhage, and jaundice. 

[The presence of perihepatitis may generally be suspected if the symp- 
toms of interference with the portal circulation have supervened during or 
soon after an attack of pleurisy of the right side, and are accompanied by 
acute pain in the region of the liver. The reaccumulation of the perito- 
neal effusion after its withdrawal by paracentesis, is usually much more 
rapid in perihepatitis than in cirrhosis, especially if the portal vein be 
compressed, at its point of entrance into the liver, by the products of the 
inflammation.] 



CONGESTION OP THE LIVER. 



691 



D. Treatment of Cirrhosis. 

As regards hobnailed liver, more important than its treatment by medi- 
cine is the avoidance of those habits of indulgence in alcoholic drinks on 
which it seems mainly to depend — and it should be borne in mind that it 
is not so much the occasionally getting drunk which is dangerous in this 
respect, as the habit of constant tippling. Even if the disease be in pro- 
gress, the discontinuance of this habit must be of real benefit to the patient, 
inasmuch as that condition which keeps the morbid process active then 
ceases. It is important that this fact should not be forgotten ; for the vic- 
tim of atrophic cirrhosis for the most part so craves for his accustomed 
stimulant that the physician is apt unwisely to indulge him in his cravings. 
But besides abstinence from alcohol, the patient should attend carefully to 
hygienic measures ; his diet should be light, nutritious, and not too stimu- 
lating or too abundant; he should keep good hours, be warmly clad, and 
take moderate exercise. Further, he should be put under a course of vege- 
table bitters, with (especially if there be gastro-intestinal catarrh) the ad- 
dition of some stomachic. Or he may take one of the drugs often recom- 
mended for cases in which hepatic inflammation is assuming a chronic 
character : — namely, iodide of potassium, chloride of ammonium, taraxacum, 
or nitro-muriatic acid. The bowels should be kept freely open, but violent 
purging should be avoided. When the various late complications or results, 
such as ascites, hrematemesis, and melaena, dysentery, or jaundice, super- 
vene, they will of course require special treatment. But for details we 
must refer to the articles devoted to these several subjects. 

The remarks just made in regard to the treatment of atrophic cirrhosis 
are applicable in the main to the other forms of chronic hepatitis. If,, 
however, there be reason to suspect a syphilitic origin it is obvious that 
antisyphilitic remedies should be prescribed. 



Y. CONGESTION OF THE LIVER. (Nutmeg Liver.) 

Causation Congestion of the liver necessarily attends inflammation of 

the organ ; it occurs also in connection with over-eating, excessive use of 
alcohol, sedentary habits, and exposure to atmospheric influences, especi- 
ally great heat : and it is a common consequence of ague or exposure to 
malaria, and of various febrile and inflammatory disorders. The most 
interesting form, however, of congestion is probably the mechanical con- 
gestion which arises in the course of obstructive lung and heart diseases, 
more especially diseases of the mitral valve, and valves of the right side of 
the heart. It is this form of congestion alone which we shall now con- 
sider. 

Morbid anatomy Congestion of the liver is attended with more or less 

enlargement of the organ due to distension of its vessels, and mainly its 
veins and capillaries, with blood. When general the liver structure pre 
sents a more or less uniform deep-red hue, and blood escapes in abundance 
from the cut surface. In cardiac or mechanical congestion it is the hepatic 
veins and their minute branches occupying the centres of the lobules which 
are chiefly if not exclusively involved. These become dilated and full of 
blood, and the liver consequently undergoes more or less considerable in- 



692 



DISEASES OF THE DIGESTIVE ORGANS. 



crease in bulk. If sections of the organ be made at this time it will prob- 
ably be found that the centres of the lob ales are deeply congested while 
their peripheral parts are more or less markedly pale. With the progress 
of the disease the hepatic texture undergoes important changes ; in conse- 
quence of the increasing dilatation of the intra-lobular hepatic veins the 
cells which lie in their meshes undergo atrophy and perhaps finally dis- 
appear; the cells immediately bounding this region often become deeply 
jaundiced and the seat of granular biliary pigment, and haematoidine crys- 
tals are occasionally deposited ; and the peripheral cells of the lobules get 
more or less distended with oil. In this stage the liver is often larger 
than natural, though probably smaller than it was at first ; it is apt to be 
somewhat granular on the surface with a more or less thickened capsule ; 
it presents some degree of induration ; and on section the surface is found 
to be thickly studded with small circles or festoons of an opaque butf or 
bright yellow color, interwoven with discs or small lobulated patches of 
intense perhaps black congestion. The appearance has been not unaptly 
compared to that of the sectional surface of a nutmeg. It may be added 
that, in connection with atrophy of the cells of the central parts of the 
lobules, a development of fibroid tissue takes place at length, and that thus 
a condition approaching to that of cirrhosis supervenes. 

Symptoms and progress — The symptoms of congestion of the liver or 
of the congestive hepatitis which takes place in the course of obstructive 
cardiac or pulmonary disease are : uniform enlargement of the organ, which 
probably descends an inch or two below the lower margin of the right ribs, 
and encroaches to an abnormal extent on the right half of the thoracic 
cavity : pain and fulness in the hepatic region, with considerable tender- 
ness on pressure or percussion ; pain or tenderness on lying on the right 
side ; pain also in lying on the left side from the tendency of the liver to 
drag; and pain on drawing a deep breath or coughing. Slight jaundice is 
apt to supervene and to persist after all other symptoms of hepatic affec- 
tion, excepting enlargement of the organ, have subsided. It is in these 
cases that hepatic pulsation is occasionally observed. Hepatic engorge- 
ment comes on as a rule late in the progress of cardiac and pulmonary 
diseases ; and although it often subsides under treatment it is very apt 
to recur, and then to become more or less permanent. When the con- 
gestion has become chronic, and the liver shrunken and indurated, ascites 
and other consequences of portal obstruction, as in ordinary cirrhosis, are 
apt to ensue. 

The treatment of hepatic congestion is mainly of course that of the pul- 
monary or heart-disease which causes it. In other respects it may be 
regarded as identical with what has already been prescribed for inflamma- 
tion of the ducts of the liver or the earlier stages of acute hepatitis. 



VI. MORBID GROWTHS. 
A. Tubercle. 

This affection is much more common in the liver, in connection with 
tuberculosis of other organs, than is generally supposed, but has no clini- 
cal importance whatever. Miliary tubercles are most frequently met with, 
and are often present in considerable numbers ; but, owing to their close 



MORBID GROWTHS OF THE LIVER. 



693 



approximation in color to the hepatic lobules and their extreme minute- 
ness, are apt, excepting they be at the surface, to elude detection. Occa- 
sionally tubercles of the average size of a pea or bean are observed. 
These always present a central cavity full of broken-down tissue and 
biliary coloring matter, with a capsule of yellowish or grayish tubercular 
growth. 

B. Syphilis. 

Morbid anatomy Syphilitic disease is recognized post mortem chiefly 

by the presence of gummata, which have already undergone retrogressive 
changes. These are opaque, buff-colored, dense, tough masses, rounded 
or irregular in form, and varying from about the size of a pin's head to 
that of a chesnut. They are rarely solitary, and are often grouped in 
clusters of considerable bulk. They are incapable of enucleation, and are 
imbedded in dense fibroid or cicatricial tissue, which is continuous, on the 
one hand, with the bodies just described, on the other, with the surround- 
ing hepatic texture. They are mostly solid ; but occasionally, when one 
is permeated by a duct, the latter is broken down into a cavity within it. 
Wherever these masses with the surrounding cicatricial tissue are present, 
the hepatic surface which corresponds to them is thickened, drawn in, and 
sometimes very deeply indented — facts which prove the chronic nature of 
the affection, and that much contraction of tissue has attended its progress. 
Not unfrequently, in cases where many of these tumors are present, we 
also find dense masses of cicatrix-like tissue, which are either free from 
obvious tumours in their interior, or which, in place of them, present 
merely a few opaque or gritty particles. 

The conditions above described are, however, only the last phases of a 
more acute syphilitic affection. The influence of the syphilitic virus on 
the liver is in the first instance to cause interstitial inflammation, which, 
as we have shown, has considerable resemblance to that of the early stage 
of ordinary cirrhosis. This affection may be general throughout the liver, 
or confined to certain areoe ; and it is in connection with it that, sooner or 
later, gummata make their appearance. These are due to the active pro- 
liferation of certain of the cell-elements of the newly formed fibroid tissue, 
which increases in number and diminishes in size, and collectively form 
tumors which have a close resemblance to granulation tissue or tubercle 
in the early stage. These growths then rapidly degenerate in their central 
parts, while they increase peripherally, so that at an early period they 
present caseous masses surrounded by a thin rim of living cell-growth. 
After a while they cease to enlarge, and the whole mass undergoes caseous 
degeneration. Gummata may occur in any region ; they are common on 
the convex surface of the liver, and especially, as Virchow points out, in 
parts exposed to injury. They are common, also, in the neighborhood of 
the transverse fissure, and may there seriously interfere with the permea- 
bility of the ducts and vessels. They usually vary in size between that 
of a pea and that of a walnut ; but they may be larger or smaller, and are 
often aggregated. Although interstitial hepatitis is a common result of 
congenital or hereditary syphilis, the firm cheesy masses just described are 
rarely discovered in that variety of the disease. 

Symptoms The symptoms which may be looked for in hepatic syphilis 

are those of cirrhosis in its various stages, especially, therefore, ascites, 
intestinal hemorrhage, and jaundice. But it must be admitted that syphi- 



694 



DISEASES OF THE DIGESTIVE ORGANS. 



litic disease is, from first to last, often unattended with symptoms, and 
that it is not unfrequently discovered post mortem in cases where its pres- 
ence during life had never been suspected. When, however, the gum- 
matous growths obstruct the vena porta? or the hepatic duct, the symptoms 
due to such lesions will necessarily manifest themselves with considerable, 
and perhaps sudden, intensity. The detection of some irregularity of 
form, or manifest but sluggish tumor, in the liver may aid our diagnosis. 
The chief grounds, however, for suspecting the presence of syphilitic dis- 
ease in this organ would be the association of symptoms of hepatic disor- 
der with a history of syphilis and visible indications of its presence in a 
constitutional form. 

Treatment — In addition to the treatment suitable for cirrhosis and its 
consequences, the use of antisyphilitic remedies is obviously indicated in 
the treatment of hepatic syphilis. 

C. Non-malignant Growths. 

Under this head we may make a brief reference to two varieties of mor- 
bid formations which have little more than a pathological interest. These 
are simple cysts and cavernous tumors. The latter are small, blackish, 
spongy masses, rarely exceeding the size of a filbert; replacing definite 
portions of hepatic substance ; and consisting of irregular intercommuni- 
cating vascular spaces, separated from one another by trabecular of fibrous 
tissue covered with pavement epithelium. Simple cysts vary from scarcely 
visible points up to the size of an orange. They are sometimes solitary, 
and are then usually situated about the middle of the anterior edge of the 
liver. Occasionally they are present in enormous numbers, w r hen they 
display all grades of size and varieties of grouping. They are generally 
thin-walled, and in some cases give evidence of their enlargement by the 
coalescence of neighboring cysts ; they are lined with pavement epithelium, 
and usually filled with clear serous fluid. The smaller cysts sometimes 
contain yellowish or brownish colloidal masses like those found in renal 
cysts. Cysts, however numerous they may be, rarely, if ever, induce he- 
patic symptoms ; it is possible, of course, that the presence of one of large 
size in relation with the anterior edge might be detected by manual exam- 
ination ; as a matter of fact, however, they are rarely, if ever recognized 
during life. The most interesting point in connection with them is the 
fact of their comparatively frequent association with cystic developments 
in other organs, more especially in the kidneys and spleen. They must 
not be confounded with hydatid cysts. 

B. Malignant Growths. 

Morhid anatomy. — Malignant tumors of the liver are usually secondary 
to similar growths originating elsewhere in the body, and especially, per- 
haps, to such as are developed in the other chylo-poietic viscera. Not 
unfrequently, however, they are primary. No age is exempt from liability 
to the disease ; yet it rarely occurs before adult age, and is most common 
in persons of middle or advanced life. It has been met with in young 
children, and in them is probably always a secondary manifestation. The 
influence of sex is unappreciable. 

Malignant disease appears in the liver in two forms : either as isolated 
tumors or as a more or less general infiltration. In the former case the 



MORBID GROWTHS OF THE LIVER. 



695 



tumors vary in size from that of a good-sized orange, or even a cocoanut, 
down to minute granules, which the naked eye may fail to recognize. 
Their general form is globular, unless the coalescence of neighboring 
masses, or accidental circumstances, have led to their irregular develop- 
ment. When they involve the surface of the liver, those areas of disease 
which are immediately subjacent to the capsule, and which are generally 
circular, assume a peculiar cupped appearance, due to the presence of a 
more or less prominent peripheral ring, circumscribing a central concave 
depression. This cupping is very characteristic, and may frequently be 
recognized in tumors not more than a line or two in diameter as readily as 
in such as have attained the bulk of a chestnut or orange. There is usually 
more or less well-marked vascularity of the superficial aspect of these 
tumors, and especially of their peripheral portions and of the liver-struc- 
ture immediately surrounding them. The tumors grow at their margins, 
partly by progressively invading the healthy tissues bounding them, partly 
by the formation in their immediate neighborhood of new foci of disease, 
with which they gradually coalesce. But while the marginal growth is in 
progress, the central portions fall into more or less rapid degeneration. 
This may be fatty, caseous, or even calcareous, or connected with hemor- 
rhagic extravasation. Occasionally the central portions undergo liquefac- 
tion, and become converted into cysts containing a milky or watery fluid. 
These several forms of degeneration do not, as a rule, occur indiscrimi- 
nately ; each one, in fact, indicates to some extent an inherent peculiarity 
in the tumor in which it occurs, and which is shared more or less by all 
the other tumors which are in genetic relation with it. It is to the com- 
bination of active peripheral growth with central retrogression and necrosis 
that the superficial cupping to which reference has been made is mainly 
referable. Malignant tnmors may occur in any part of the hepatic sub- 
stance ; and may vary numerically from one or two to an innumerable 
multitude. In the former case they are usually primary, and it is here 
that probably the greatest size of growth is attained. In the latter they 
are generally secondary to growths elsewhere. 

The diffused or infiltrating form of malignant disease is much more rare 
than that which has just been described. In this case we find the liver 
generally, or large portions of it, greatly enlarged, but retaining their normal 
shape : the enlargement being due to the abundant dissemination of small 
growths, more or less indistinctly defined from the liver-tissue, and tending 
to run together, so as to give to both the outer and the sectional surface 
of the affected organ a more or less spotty, reticulate, or uniformly morbid 
character. Sometimes, indeed, the naked eye fails to detect in the en- 
larged liver any traces of normal hepatic tissue. The presence of distinct 
rounded tumors may be associated with the condition here described. 

Of the several forms of malignant disease which attack the liver, the 
carcinomata are the most common. The variety of cancer most frequently 
met with is the encephaloid, of which several sub-varieties, not, however, 
calling for description, exist ; scirrhus is more rare ; and still rarer than 
scirrhus are melanotic cancer and colloid cancer. Most of these appear 
under the form of isolated scattered masses. Sarcomatous malignant 
growths are comparatively unfrequent. The most common and interesting 
of them is the melanotic variety, which is usually secondary to similar 
disease of the choroid coat of the eye, or of pigmentary naevi. Melanosis 
is usually very widely distributed throughout the organ ; the tumors are 
small and tend to coalesce ; and the condition above described as 1 infil- 



696 



DISEASES OF THE DIGESTIVE ORGANS. 



trating' is apt to be produced ; the liver often becomes enormously enlarged, 
and assumes, from the intermingling of melanotic spots with spots of color- 
less growth and remnants of hepatic texture, an appearance which has 
been aptly likened to that of granite. Melanotic masses of considerable 
bulk, however, are not uncommon. Other forms of sarcoma — spindle- 
celled sarcoma, for example, and the closely related myxoma — have been 
discovered in the liver, secondary to similar growths in remote organs. 
True epithelioma of the liver is scarcely more than a pathological curiosity. 
Cylindrical-celled epithelioma, however, or adenoma, secondary, for the 
most part, to gastro-intestinal disease of the same kind, is of much more 
frequent occurrence. Its tumors are scarcely distinguishable, excepting 
microscopically, from those of ordinary carcinoma. Lastly, lympho-sar- 
coma, or lymphadenoma, is often developed in the liver. This may form 
independent tumors, like carcinoma, but seems specially to affect the 
capsule of Glisson and the interlobular tracts ; so that, in some cases, it 
involves the liver by ramifying through it with the portal vessels, in some 
it follows the ordinary distribution of the fibrous growth of atrophic cir- 
rhosis, but in either case is apt to develop here and there into manifest 
tumors. Other forms of malignant disease besides lymphadenoma are 
liable to invade the liver from the transverse fissure. In cases of gastric 
or peritoneal cancer especially, the small omentum is very commonly infil- 
trated with cancerous growth, which thence propagates itself along Glis- 
son's capsule, surrounding and compressing, or otherwise involving the 
veins and ducts. Again, the lymphatic glands in this situation are often 
affected secondarily to hepatic or other neighboring malignant disease, 
and may then by their enlargement more or less seriously implicate the 
same channels. 

Symptoms and progress — The symptoms which attend malignant dis- 
ease of the liver are in the main identical with those of cirrhosis and other 
structural diseases of the same organ. They comprise : alterations in the 
form and size of the organ, with local pain or uneasiness ; impediment, 
mechanical or other, to the due performance of the hepatic functions ; 
mechanical interference with the functions of neighboring organs ; and 
general impairment of nutrition. Increase of size and alteration of shape 
furnish very important indications of the presence of hepatic malignant 
tumors. The increase may be either uniform, or, as is more commonly 
the case, dependent on the formation of rounded projecting lumps, which 
may often be readily distinguished by the hand. Mere increase of size, 
however, is not so indicative of the morbid conditions in question as is 
rapid progressive increase; nor is the simple fact of the presence of irre- 
gularity from outgrowths so suggestive as the progressive enlargement and 
development of such excrescences, and the existence of a certain degree of 
hardness and resistance which is not usually observed in mere cystic for- 
mations. It must be borne in mind, however, that malignant disease is 
often present in a liver which is not noticeably altered in form or size : 
the growths may be few and small, or they may occupy the posterior part 
of the organ, or the liver itself may be concealed by the overlapping of 
distended and adherent bowel, or by other conditions. And, further, t 
tumors of the stomach, or of the retro-peritoneal glands, and even of the 
abdominal Avails, may seem from their position to be of hepatic origin. 
Pain is, no doubt, a frequent attendant on hepatic malignant disease. 
Sometimes it is excruciating, and apt to come on in paroxysms ; but it is 
often absent, and may be totally absent from first to last. Jaundice, 



MORBID GROWTHS OF THE LIVER. 



697 



usually clue to obstruction of some of the hepatic ducts, makes its appear- 
ance sooner or later in a considerable number of cases. It is rarely intense, 
unless the main duct be involved ; and hence it is chiefly in those cases 
in which the disease attacks the lesser omentum, and extends thence into 
the transverse fissure, that deep jaundice becomes developed. Jaundice, 
however, is by no means a necessary result, and is not unfrequently absent 
from the most extreme cases — cases in which the whole hepatic texture 
seems to be replaced by the morbid growth. Ascites is, perhaps, even 
more rarely than jaundice, a direct consequence of malignant disease of 
the liver. It is often, no doubt, developed during the progress of the case, 
and may be due, as in cirrhosis, to impediment to the flow of blood through 
the portal vessels ; but it is usually comparatively small in amount, and 
dependent either on peritoneal inflammation or on other abdominal com- 
plications. When, however, the portal vein is distinctly obstructed, the 
ascites may be considerable, and other consequences of portal obstruction, 
such as melsena, may ensue. In most cases ascites is absent. As regards 
neighboring organs, the pressure of the enlarged and possibly painful liver 
is apt to induce functional disturbance of the stomach on the one hand, 
and pain and difficulty of breathing, and perhaps cough, on the other. 
General impairment of nutrition, debility, and emaciation are usually 
marked phenomena of the progress . of the disease. Scanty secretion of 
urine, with abundant deposit of vermillion- or carmine-colored urates, is 
commonly observed. 

In most cases, malignant disease of the liver is associated with similar 
disease of other organs; and the symptoms which the patient presents are, 
therefore, of complicated origin. This fact, while it may be of the greatest 
value in enabling us to form a correct diagnosis of the malady under which 
he is laboring, often renders it difficult to determine how much and which 
of his sufferings are due to the hepatic lesion. As of malignant disease 
generally, so no doubt of that affecting only the liver, it may be regarded 
as generally true : that the symptoms are insidious and progressive ; that 
the disease has usually made more or less considerable progress before the 
suspicion arises that the patient is ill ; that this suspicion is first aroused, 
either by the gradual creeping on of emaciation, debility, and cachexia, or 
by the slow supervention of gastric symptoms, or by a sense of fulness, 
heat, or pain — continuous or paroxysmal — in the hepatic region, or lastly 
by the discovery of obvious tumors. During the further progress of the 
case all the symptoms of this period of invasion are apt to become com- 
mingled, and the special phenomena which we have attributed to the 
declared disease to supervene. It must not, however, be forgotten that 
malignant disease of the liver may prove fatal without having ever been 
attended with some of those symptoms which would seem to be most 
typical of it : not only, as we have pointed out, may there never be obvious 
tumor, hepatic pain, jaundice, ascites, or distinct impairment of the digestive 
functions, but the so-called 'cancerous cachexia' may never be distinguish- 
able, and the patient, instead of becoming emaciated, may remain in good 
flesh, or even become fat. 

From the difficulty of determining the date at which it commences, it 
is impossible to determine, even approximately, the duration of hepatic 
malignant disease. Nor is it important to do so. It is sufficient for 
practical purposes to know : that when once the disease has given clear 
evidence of its presence, the patient rarely survives beyond twelve months ; 
and that generally his death occurs within six or eight months. The 



698 



DISEASES OF THE DIGESTIVE ORGANS. 



natural cause of death is gradually increasing asthenia ; but the fatal 
event is apt to be accelerated by the occurrence of peritonitis or other 
complications. 

Treatment. — Medical skill is powerless to arrest the progress of the 
morbid growths under consideration. All that the physician can do is to 
relieve pain and uneasiness by opium or other sedatives, or by local 
measures ; to check vomiting ; to obviate constipation ; and generally to 
aim at relieving the various symptoms which distress the patient ; and by 
hygienic and other measures to maintain, as far as possible, his general 
health and strength. 



VII. HYDATIDS OF THE LIVER. 

Morbid anatomy — These parasites affect the liver more frequently 
than any other organ ; they are not uncommonly developed, however, in 
various parts of the sub-peritoneal connective tissue, more especially that 
of the pelvis. In the liver hydatid tumors are usually solitary ; but some- 
times two or more are developed there simultaneously ; and occasionally 
also such tumors in the liver are associated with other similar tumors 
elsewhere in the abdominal cavity. Their size varies ; they are not un- 
frequently met with as large as a child's head, and containing several 
pints of fluid ; but they are slow in attaining these dimensions ; and 
although the exact period during which they live and grow is uncertain, 
there is no doubt that it occasionally extends to at least ten or fifteen 
years, possibly even to twenty or thirty. They are for the most part 
globular in form, unless bands or ligatures, or other accidental conditions, 
have interfered with their development. In the liver they most frequently 
involve the right lobe, a fact which is probably due simply to its compara- 
tively large size. Hydatids appear to originate in the hepatic substance, 
which becomes displaced by them in the course of their development, and 
at the same time the seat of fibroid growth and induration in the layer 
which immediately surrounds them. By this means a kind of fibrous 
capsule is formed. In most cases there is no communication between the 
hydatid tumor and the hepatic ducts ; sometimes, however, a large, and 
even a primary, duct may be found leading directly into the cavity, and 
its open continuation and that of some of its branches, studded with the 
orifices of their numerous tributaries, may then be seen ramifying upon its 
walls. The normal event of hydatid tumors, and one which is fortunately 
far from uncommon, is the death of the parasite, and the degeneration and 
contraction of the tumor. This has already been sufficiently described ; 
it may, however, be added that hsematoidine crystals, derived from the 
biliary coloring matter, are not unfrequently met with in such degenerated 
cysts. Other events of not uncommon occurrence are the rupture of the 
cyst by accidental violence and its suppuration. 

Symptoms and progress Hydatid tumors are rarely attended with 

pain, or even uneasiness, excepting by reason of their bulk, and the pres- 
sure they exert on neighboring parts, or in consequence of the superven- 
tion of inflammation. It generally happens, indeed, that the patient's 
attention, or that of friends, is first attracted by the discovery of gradual 
and at the same time more or less unsymmetrical abdominal swelling. 



HYDATIDS OF THE LIVER. 



G99 



So that when the case first comes under medical observation there is 
generally an obvious tumor in some part of the abdomen, and the question 
is consequently not so much whether or not a tumor is present, as what 
the nature of the existing tumor is. 

Uninflamed hydatid tumors, which abut upon the surface, usually appear 
as rounded, tense, elastic swellings, free from pain or tenderness. They 
often fluctuate distinctly, and are not unfrequently attended with the 
peculiar hydatid thrill first described by Brian con and Piorry. This, 
which is best recognized by placing the left hand flat upon the tumor, and 
then percussing sharply with the fingers of the right hand, consists in a 
peculiarly long-sustained tremor, reminding one of that experienced on an 
iron railway bridge during the passage of a train over it. The nature of 
the swelling, however, may generally be placed beyond the possibility of 
doubt by tapping. The fluid which comes away from the living hydatid 
cyst is transparent and colorless like water, limpid, containing an excessive 
quantity of chloride of sodium, and as a rule neither albumen nor fibrinogen. 
Its specific gravity varies from about 1008 to 1013 ; and its reaction is 
neutral or slightly alkaline. Further, it may contain echinococci or 
microscopic hydatids. The position of the tumor will necessarily vary 
with its seat of development. If in the liver, it perhaps most commonly 
projects forwards — occupying the scrobiculus, or this with more or less of 
the adjoining abdominal regions ; but it may also protrude directly up- 
wards, pushing the heart before it upwards and to the left ; or it may 
displace the right half of the diaphragm, together with the base of the 
lung, at the same time distending the lowermost zone of the right side of 
the chest ; or again it may be developed in the posterior region of the 
liver, and so elude deduction. It is impossible to lay down any rules with 
regard to the situation of the tumor when it originates in other parts of 
the abdominal cavity. Suffice it to say : that it may, according to cir- 
cumstances, assume the position of a renal, omental, ovarian, uterine, 
aneurismal, or other growth ; and that it is with these mainly (especially 
if they be cystic) and with hepatic swellings, more especially abscesses and 
dilated gall-bladders, that hydatid tumors may be confounded. When 
displacing the right lung upwards, and distending the corresponding part 
of the chest, they may simulate pleuritic effusion. Further, an hydatid 
cyst may be separated from the surface by a considerable thickness of the 
tissue in which it originates, or by an exceedingly thick and dense capsule, 
and hence may be mistaken for a solid tumor ; or owing to the simultaneous 
development of several cysts, or to various other accidental circumstances, 
it may appear nodulated or multiple, and may present different degrees of 
consistence and elasticity at different points, and so may easily be taken 
for a lobulated malignant growth, or for a compound ovarian or other 
cystic tumor. The diagnosis of a contracted and degenerated cyst, even 
if occupying a situation readily accessible to examination, would, without 
the guidance of a clear history, be exceedingly difficult, if not impossible. 

Hydatid tumors are not always unattended with symptoms ; they may, 
from their bulk or situation, interfere seriously with respiration; they 
may cause vomiting and other dyspeptic phenomena ; they may compress 
the hepatic ducts and so induce jaundice, or the portal vein, causing 
ascites, or the inferior cava, leading to anasarca of the lower extremities 
and probably congestion of the kidneys; and hence by the gradual super- 
vention of asphyxia, asthenia, or other conditions, death may after a 
while ensue. The sudden rupture of hydatid tumors, with the escape of 



700 DISEASES OF THE DIGESTIVE ORGANS. 

their contents into the peritoneal cavity, is usually followed by rapidly 
fatal peritonitis. The symptoms due to suppuration are sometimes ob- 
scure, sometimes very well-marked ; they are those, -however, which 
usually attend extensive suppurative inflammation. The hydatid cyst in 
fact becomes converted into an abscess, and comports itself in its further 
progress exactly as any other large hepatic abscess. It increases more or 
less rapidly in size, and after a while discharges its contents either at the 
external abdominal surface, into the pleura, through the lung, into the 
pericardium, into the stomach, intestine, or abdominal cavity, or into the 
hepatic ducts and thence into the duodenum. Other rare terminations 
have been met with, such as by perforation of the vena cava, or right 
auricle of the heart. The proof that an hepatic or abdominal abscess is 
of hydatid origin rests on the discovery of hydatid membranes, echinococci 
or their debris in the pus which escapes. The hooklets, which are pecu- 
liarly indestructible, should especially be looked for. 

Treatment. — No medicinal treatment avails either to cause the death of 
hydatids or to arrest their growth. For the cure of the disease we must 
look to local measures only ; and these consist mainly in the evacuation of 
the contents of the cysts. The puncture of the cyst with a bistoury,. or a 
trocar and cannula sufficiently large to admit of the escape of the cystic 
progeny of the parent hydatid, is a procedure which has been largely 
adopted. It is obvious, however, that it can only be employed with safety 
when the cyst is adherent to the abdominal parietes, and the escape of the 
contents into the peritoneal cavity thus prevented. It can only be justi- 
fiably had recourse to, therefore, when the cyst has undergone inflamma- 
tion or suppuration and has consequently got united with the surface over 
it ; or after measures have been taken to insure the formation of adhesions. 
Among methods which may be adopted to effect this object are : first, 
incision through the abdominal parietes until the cyst is exposed ; second, 
the gradual destruction by caustics of a limited area of the abdominal walls 
down to the parietal peritoneum over the intended seat of operation ; and, 
third, Trousseau's method of multiple acupuncture. In all such cases it 
is essential that the patient should be kept at rest, and the abdominal 
walls in close apposition with the subjacent cyst-walls by means of pres- 
sure, in order to insure the formation of adhesions and their maintenance 
when formed. 

A far better plan, however, for evacuating the contents in all those 
cases in which suppuration has not yet occurred, is that which was 
strongly recommended some years since by Moissenet, and has since been 
successfully employed in this country, and especially in the Middlesex 
Hospital by Drs. Greenhow and Murchison. It consists in the employ- 
ment of an exceedingly fine trocar and cannula. The minute puncture 
made by this instrument rarely permits, even if no adhesions be present, 
of the escape Of any appreciable quantity of the hydatid fluid into the 
peritoneal cavity, and is rarely, therefore, followed by grave peritoneal 
complications. In order, however, to guard against such accidents it is 
well to select some prominent and central portion of the hydatid protuber- 
ance for puncture, to refrain from removing the whole of the contents at 
one operation, and after the operation to keep the patient at perfect rest 
and the punctured parts in close apposition by means of a compress and 
bandage. It is further desirable to preclude the entrance of atmospheric 
air, and for this reason also, if the aspirator be not employed, to be con- 
tent with the partial evacuation of the cyst. In consequence of the opera- 



HYDATIDS OF THE LIVER. 



701 



tion the hydatid collapses, and falls away from the walls of the adventi- 
tious cyst in which it is contained. The space thus formed becomes filled 
to a greater or less extent with serous exudation which soon gets turbid : 
and the hydatid bathed in the unwonted fluid generally soon perishes. 
The cyst, shortly after paracentesis, may become nearly as tense as it was 
originally ; but generally it begins to shrink again before long, and then 
gradually undergoes cure. The operation does not generally need to be 
repeated. Another method of treatment has been recommended by Dr. 
Althaus, and successfully practised by Dr. Fagge and Mr. Durham. The 
details are furnished by Dr. Fagge in the following words : ' Two electro- 
lytic needles are passed into the tumor one or two inches apart, they are 
then attached to two metallic wires, both connected with the negative 
pole of a battery of ten cells. A moistened sponge forms the termination 
of the positive pole, and is placed on the patient's skin at a little distance 
from the point of entrance of the needles. Its position is changed from 
time to time during the operation. The current is allowed to pass for 
about ten minutes. At the end of this time the needles are gently with- 
drawn and the seats of puncture covered with adhesive plaster.' The 
above operation is often attended with some escape of fluid into the ab- 
dominal cavity, and some rise of temperature with other febrile symptoms. 
And as with simple paracentesis, so here, the immediate effects are not 
always obvious. The operation may need to be repeated. It has been 
recommended by some that after the evacuation of more or less of the con- 
tents of the cyst, a solution of iodine, perchloride of iron, bile or some 
other antiseptic or parasiticidal fluid should be injected ; and this practice 
has in some cases been successful. It is obvious, however, that the injec- 
tion of irritating fluids is apt to induce inflammation and suppuration, 
which are in themselves very undesirable; and it is at least doubtful 
whether the death of the parasite is more surely attained by this proce- 
dure than it is by the simple evacuation of the fluid contents. If unfor- 
tunately peritoneal inflammation ensue, it must be combated by appro- 
priate treatment. If suppuration of the cyst take place (and this is an 
accident for which we must be prepared), it will also be necessary to ac- 
commodate our treatment to the altered condition of things. But espe- 
cially the local treatment will need some modification. It will then at all 
events be desirable, so soon as we are satisfied that the cyst is adherent, 
that a free opening be made, and the contents, inclusive of the hydatid 
cysts, freely evacuated. Whether, however, that opening should be made 
with the trocar and cannula, or the knife ; or whether it should be allowed 
to close or be kept open ; and in the latter case whether the contents 
should be allowed to escape by means of a drainage tube or not; or 
whether the cavity should be washed out with some disinfectant solution ; 
are points on which it is difficult to express oneself absolutely. The exi- 
gencies of cases as they arise necessarily call for modification in the details 
of treatment. It is needless to discuss the treatment of the numerous 
other accidents and complications which are apt to manifest themselves 
during the course of hydatid disease. 



702 



DISEASES OF THE DIGESTIVE ORGANS. 



VIII. FATTY LIVER. 

Causation — The deposition of fat globules in the hepatic cells is not 
necessarily an indication of disease. It is frequently observed to a small 
extent in health ; and sometimes indeed to a large extent in healthy per- 
sons who lead sedentary lives, or feed largely, especially those whose diet 
comprises an excess of fatty matter, or who have a tendency to obesity. 
That abundant deposition of fat, however, which constitutes what is meant 
by ' fatty liver,' is usually associated with various morbid states either of 
the system or of the liver itself. Among the former of these we may enu- 
merate chronic alcoholism, heart disease, malignant cachexia, and especially 
pulmonary phthisis ; among the latter cirrhosis, lardaceous degeneration, 
and the indurated condition which supervenes on chronic cardiac or pul- 
monary affections. 

Morbid anatomy In the early stage fat globules of small size are found 

scattered in the substance of the hepatic cells ; at a later period many of 
the globules have enlarged, partly by coalescence, partly by fresh deposi- 
tion, and may then considerably exceed in size the nuclei around which 
they cluster : at a still later period complete coalescence takes place, and 
the cells distended with their oily contents assume very much the appear- 
ance of the cells of adipose tissue. The deposition of fat always com- 
mences at the periphery of the hepatic lobules, and is very often limited 
to that part ; and even when the change becomes universal it is still this 
outer zone which chiefly suffers. The presence of fat in any abundance 
renders the affected portion of the liver coarse, soft, dull, and opaque — the 
yellowness due to bile and the redness due to blood alike disappearing in 
a greater or less degree. Further, the tissue often becomes distinctly 
greasy, the fat adhering to the knife and fingers. It often happens in 
cirrhosis that the isolated nodules of hepatic substance are more or less 
loaded with oil. In lardaceous change scattered patches of hepatic tissue 
are not unfrequently similarly affected. In cardiac and chronic lung dis- 
ease the deposition is mostly limited to the peripheral parts of lobules ; 
and indeed it is owing mainly to the contrast between the outer fatty and 
anaemic zones and the central deeply congested areas, that the term 'nut- 
meg' has been applied to this form of hepatic affection. It is not uncom- 
mon to find the fatty and the congested regions of the lobules separated 
from one another by a line of deep jaundice. In the fatty liver of phthisis 
and other wasting diseases, the fatty accumulation may still be mainly 
peripheral, and the liver may consequently present something of the nut- 
meg character ; but not unfrequently the organ is pretty generally involved. 
Under these circumstances it presents a nearly uniform pallor, dulness of 
aspect, and softness, and its bulk is generally very largely increased. 
The enlargement of fatty liver is as nearly as possible uniform. The fat 
consists mainly of olein and margarin, with traces of cholesterine. Its 
amount varies ; in extreme cases from 43 to 45 per cent, of the hepatic 
substance has been found to consist of fat, and indeed after the removal 
of the water Frerichs has found no less than 78 per cent, of the residue to 
be fat. 

Symptoms It is natural to believe that excessive accumulation of fat 

in the liver would seriously affect the functions of that organ ; and many 
different symptoms have been ascribed to it. We are bound, however, to 
confess that we have never met with a case in which hepatic or other de- 



LARDACEOUS LIVER. 



703 



rangement has been clearly attributable to it. And, indeed, it must not 
be forgotten that fatty accumulation is frequently associated with structural 
changes in the liver ; and that, when under such circumstances hepatic 
symptoms are present, they are probably referable to these associated lesions. 
The enlargement due to fatty deposition in the liver may often be recog- 
nized during life, and occasionally the augmented bulk of the organ pro- 
duces fulness, weight, and uneasiness in the side. 

Treatment. — When fatty liver depends on actual disease, it is essentially 
by treating the disease that we must hope to remove the hepatic accumu- 
lation. When we have reason to believe that enlargement of the liver, 
in persons who are fairly healthy, is due to fatty deposit, our treatment 
must be guided by our knowledge of their habits and tendencies, and 
must necessarily be mainly hygienic. It is very seldom 7 however, that 
we shall be called upon to make fatty liver a distinct object of medical 
treatment. 



IX. LARDACEOUS LIVER. 

Causation — This affection is secondary to those morbid conditions of the 
system in which general lardaceous disease takes its origin : especially 
chronic phthisis, tertiary syphilis, caries of bone, and other conditions at- 
tended with prolonged suppuration. 

Morbid anatomy The lardaceous change takes place first, according 

to Rindfleisch, in what he terms the arterial zone of the hepatic lobules? 
that is, midway between the centre and periphery, implicating both the 
minute arteries and capillaries of the part, and the hepatic cells. But 
soon the morbid process extends to the central portions of the lobules, and 
after a time the periphery becomes equally involved. The change is at- 
tended : with great thickening of the affected vessels, and the acquisition 
by them of a peculiar homogeneous pellucid character ; and with consider- 
able enlargement of the hepatic cells, which lose all trace of granules, 
bile-pigment, and nucleus, and become irregular or botryoidal vitreous- 
looking lumps, which after a while break down into irregular fragments. 
The lardaceous liver, like the fatty, undergoes uniform enlargement in all 
its dimensions. It becomes smooth, heavy, and of somewhat doughy con- 
sistence ; and if uniformly affected, presents a remarkably homogeneous 
sectional surface, of a grayish tint, with a peculiar glistening, or rather, 
perhaps, semi-translucent aspect, which has some resemblance to that of 
beeswax. It is equally free from biliary and vascular congestion, and 
from moisture. The lardaceous change is not unfrequently associated with 
more or less fatty deposit, sometimes with cirrhosis, sometimes with syphi- 
litic disease. 

The size which the lardaceous liver may attain is almost unlimited. 
It has been met with weighing between ten and fifteen pounds. This in- 
crease of bulk is, however, a slow process, and often extends over some 
years. 

Symptoms — The circumstances which in combination justify the diag- 
nosis of this affection are the slow but continuous uniform enlargement of 
the liver, without pain or obvious hepatic symptoms ; the long continuance 
of some one of these morbid conditions which we know to be conducive 
to lardaceous degeneration ; and the coetaneous enlargement of the spleen, 



704 



DISEASES OF THE DIGESTIVE ORGANS. 



and involvement of the kidneys. There is no doubt that patients with 
lardaceous liver manifest, as a rule, marked cachectic symptoms ; but there 
is little evidence to show that these are dependent in any peculiar degree 
upon the hepatic disease. It is true that a slight icteroid tinge occasion- 
ally manifests itself after a while, and that the bile in the gall-bladder and 
ducts is usually pale and watery ; but, on the other hand, there is never 
obvious pain in the region of the liver, never deep jaundice, rarely, if ever, 
ascites, and (beycmd the occasional presence of bile-pigment in the urine) 
nothing in that secretion distinctly to indicate impairment of hepatic func- 
tion. The greater number of cases in which lardaceous disease manifests 
itself no doubt end fatally ; but there is reason to believe with Frerichs that 
if the change be not far advanced, the arrest of the morbid process upon 
which it is dependent may be followed by the restoration of the lardaceous 
organs to the condition of health. 

The treatment of lardaceous degeneration merges in the treatment of 
the disease which produces it. 



X. GALL-STONES. 

Very little of practical importance is as yet known with respect to the 
variations in quality and quantity of the bile, and the influence of these 
variations on the action of the bowels, the assimilation of alimentary mat- 
ters, and the general health. We know, no doubt, that when the bile 
which enters the duodenum is deficient in quantity, fatty matters are im- 
perfectly assimilated, the evacuations are fetid, and the bowels usually 
constipated; and we have reason to believe that when there is an excessive 
discharge of bile, bilious diarrhoea and vomiting may be excited ; but, on 
the other hand, we know that in many diseases, whether of the liver itself 
or of the general organism, the bile is found post mortem deviating widely 
from its normal condition, and yet there have been no symptoms during 
life which could be distinctly referred to this deviation. There is one 
abnormal condition of the bile, however, of great practical interest, which 
reveals itself to us, not directly by any of the consequences just enume- 
rated, but by the formation of concretions which bring with them special 
symptoms and special dangers. 

Causation The origin of gall-stones is obscure. It is easy, of course, 

to understand their increase of size by the accretion of additional solid 
matter ; but it is not generally easy to determine the cause of the first step 
in their development, namely, the formation of a nucleus. In some rare 
cases this has been found to be a fragment of a needle, a dead entozoon, a 
small blood-clot, or (according to Dr. Thudichum) portions of the epithe- 
lial lining of the gall-ducts. In the majority of cases, however, it consists 
of a mass of concreted biliary coloring matter. Concentration and stagna- 
tion of bile have doubtless some influence over the production of gall-stones, 
as is shown by their much more frequent formation in the gall-bladder 
than in the hepatic ducts, and probably also by their comparative fre- 
quency in cases of carcinoma, and other organic diseases of the liver. It 
is not clear that the tendency to biliary calculi is inherited, or that it is 
ever traceable to any dyscrasia, notwithstanding the statements which are 
made to the effect that it is generally associated with gout, renal calculi, 



GALL-STONES. 



705 



or other maladies. On the other hand, we know that gall-stones occur 
much more frequently in women than in men, and rarely in either sex 
below the age of thirty. They are occasionally met with, however, at 
earlier periods of life, and even in infancy. There is reason also to believe 
that they specially affect persons of sedentary habits. The influence of 
diet is unknown. 

Morbid anatomy Gall-stones vary in size from mere granules up to 

masses moulded to the form of the gall-bladder, and measuring three or 
four inches in length, from one to one and a half inches in thickness, and 
weighing between one and two ounces. When they are minute (less in 
size, say, than a poppy-seed), they are usually spoken of as biliary gravel. 
Gall-stones may be solitary ; but they are much more frequently multiple, 
and, indeed, many have been found at one and the same time scattered 
throughout the biliary ducts, and several hundreds in the gall-bladder. 
When occupying the latter cavity their size has necessarily some relation 
to their number ; at all events, when they are very numerous, they cannot 
possibly be large; whereas solitary calculi, and calculi occurring in groups 
of two or three, often attain considerable dimensions. The forms which 
they assume depend mainly on their relations, during growth, to the sur- 
rounding parts. In the commencement they may be rounded or amor- 
phous accumulations of biliary coloring matter, or even rhomboidal tablets 
of cholesterine. But with increase of size some modification takes place. 
They may acquire a branched or coral-like form in the smaller bile-ducts ; 
in the larger ducts or in the gall-bladder they may either form roundish 
masses, or accommodate their general shape to that of the cavity which 
contains them ; but when, in the gall-bladder, the simultaneous develop- 
ment of many calculi takes place, they mutually interfere with each other's 
growth, and instead of assuming a globular form, become polyhedral or 
faceted, or flattened one against the other. In this manner the bladder 
may get uniformly distended with a pyriform mass of closely-packed, 
mutually-fitting gall-stones ; and, indeed, it generally happens that, when 
its cavity appears to be occupied by a single large calculus, this consists 
of at least two or three, and generally more, well-articulated but distinct 
masses. 

Gall-stones are usually smooth, but sometimes granular or tuberculated, 
and vary in color from milk-white, through yellow or brown, to deep red- 
dish or greenish-black. Their specific gravity ranges between # 8 and 1*15 ; 
they are as a rule, however, heavier than water, and sink in it, excepting 
when they have undergone desiccation. In some cases they are so soft 
and friable as readily to fall to powder between the finger and thumb; and 
generally they are sufficiently soft to admit of being readily crushed into 
irregular fragments, or of being cut with a knife. They are usually soapy 
or greasy to the touch. As to their general structure, they sometimes 
consist of a simple tuberculated accumulation of pigmentary matter, some- 
times of a nearly homogeneous w r axy mass. In most cases, however, three 
regions may be more or less obviously recognized : namely, a central 
nucleus, which, as has already been stated, is mostly pigmentary and often 
irregular in form and shrunken ; a zone of variable thickness around this, 
which is more or less homogeneous in texture, but marked with radial 
lines ; and a cortical lamina, also of variable thickness, which is usually 
concentrically striated. These several regions are further characterized 
by differences of color. 

The chief constituent of gall-stones is cholesterine, and this forms on 
45 



706 



DISEASES OF THE DIGESTIVE ORGANS. 



the average from 70 to 80 per cent, of the entire mass : but in addition to 
this, biliary coloring matter, biliary acids, and lime are found in various 
proportions. Other ingredients are so rare or so small in quantity as 
scarcely, from a clinical point of view, to be worth consideration. They 
are chiefly the fatty acids, uric acid, earthy phosphates, alkaline salts, and 
mucus. Calculi consist sometimes almost entirely of pigmentary matter, 
sometimes mainly of carbonate of lime with some admixture of phosphate, 
and sometimes of pure cholesterine. Moreover, the different laminae often 
differ in composition, the outer shell of large calculi frequently presenting 
an excess of earthy salts. 

The consequences of biliary calculi are various. In many cases they 
form in the gall-bladder, and slowly grow there until, moulded to its shape, 
they entirely fill it; the gall-bladder contracts upon them, ceases to per- 
form its proper functions, and becomes merely the capsule of what then 
probably proves to be an inert mass. Sometimes the presence of these 
bodies irritates the mucous membrane of the bladder into inflammation, 
and, it may be, into suppuration and ulceration. Slight attacks of in- 
flammation doubtless arise occasionally and subside again without further 
result. But when the inflammation is of a more intense character, the 
cavity of the bladder may be converted into an abscess which discharges 
itself either per vias naturales, or by some abnormal channel ; or the 
mucous surface of the bladder may at some point or other be fretted by 
its contained calculi into an ulcer which, gradually eating its way through 
the parietes (then probably glued to some neighboring part) forms a sinus 
or diverticulum which, like the abscess, may open in one of several direc- 
tions. The most common routes are externally through the abdominal 
walls, into the duodenum, and into the transverse colon. But the opening 
may also take place into the stomach, peritoneum, pleura, or lung. In 
many cases a gall-stone becomes dislodged, and slips into the cystic duct, 
whence it may pass slowly onwards until it reaches the duodenum. The 
duration of this process is very variable ; in some cases it is over in a few 
hours, more frequently it occupies several days. The stone generally 
travels by fits and starts, and may be either temporarily or permanently 
arrested in any part of the channel along which it passes. If arrested in 
the cystic duct, it probably leads to its complete closure and to the enforced 
disuse of the gall-gladder, which may then either shrivel away or dilate 
into a mucous or serous cyst ; if arrested in the common duct, it probably 
sooner or later obstructs the flow of bile, which then accumulates in the 
gall-bladder and ducts ramifying in the liver, and distends them. Fur- 
ther, in either of these situations, the presence of the stone may fret the 
surface against which it lies, and cause ulceration and possibly perforation, 
and thus lead to the formation of a local abscess, or to general peritonitis, 
or to some abnormal communication with the duodenum, colon, or portal 
vein. When once a gall-stone has descended from the gall-bladder, other 
stones, if they exist, are apt to follow ; and moreover, their passage is 
generally more readily and speedily effected than that of their pioneer. 

Symptoms and progress The presence of gall-stones in the bladder 

or hepatic ducts does not necessarily cause symptoms, and in a large num- 
ber of cases is from first to last unattended with symptoms. Gall-stones 
may, however, occasionally be recognized, in consequence of forming an 
irregular, hard, and sometimes crepitating lump in the situation of the 
gall-bladder. When their presence excites inflammation, we may look 
for tenderness-, pain, and fulness in the same neighborhood, with more or 



GALL-STONES. 



707 



less obvious febrile disturbance. But unless any more distinctive phenom- 
ena arise, the exact nature of the affection can scarcely be diagnosed 
positively. Such phenomena are : the formation of an abscess superficial 
to the bladder in the abdominal parietes, and the ultimate escape of gall- 
stones with the other contents of the abscess ; and the discharge of gall- 
stones through an ulcerated opening into the duodenum or colon, and their 
escape with the feces, or their arrest in the small intestine, followed by 
enteritic symptoms. It must not be forgotten, however, that each of these 
phenomena may arise without having been preceded by any clear symp- 
toms of inflammation of the gall-bladder. 

The symptoms most characteristic of the presence of gall-stones are 
those which depend on their dislodgment and subsequent passage along 
the cystic and common ducts. They resemble in many important respects 
those due to the transit of a renal calculus along the ureter, and are mainly : 
more or less severe pain, coming on suddenly, and lasting with irregular 
intermissions and exacerbations a few hours or several days; faintness, 
nausea, and vomiting ; and the consequences of impediment to the escape 
of bile into the intestines. The pain (frequently termed hepatic colic) 
varies in its intensity, situation, and quality. Sometimes it is compara- 
tively slight, sometimes so severe that the patient writhes and cries out 
with agony; its character is aching, cutting, tearing, or burning, and it 
is generally attended with an unbearable sense of tightness, constriction, 
or cramp. It is usually referred to the pit of the stomach or to the um- 
bilicus, whence it extends to the back between the shoulders, to the chest 
or to the shoulder-tip, or down into the lower part of the abdomen. But 
its situation is often somewhat indefinite, and may be such as to simulate 
the passage of a stone along the ureter. There is seldom any material 
tenderness, and pressure sometimes affords relief to the pain. Hepatic 
colic is said to be further characterized by often coming on suddenly two 
or three hours after a meal, at the time when the passage of food along 
the duodenum excites the flow of bile from the gall-bladder and biliary 
passages. It often comes to a sudden end in consequence either of the 
slipping back of the stone into the gall-bladder, of its arrest at some 
point in the course of the cystic or common duct, or of its escape into 
the bowel. The faintness, nausea, and vomiting are not in necessary 
relation with the severity of the pain ; the patient may be simply chilly, 
or he may have severe rigors ; he may merely feel faint, or he may fall 
into a state of actual syncope or collapse, with cold and pallid surface, 
profuse perspirations, and imperceptible pulse ; he may complain simply of 
nausea, or he may suffer from severe and protracted vomiting. The syn- 
copic attack has proved fatal. A gall-stone may pass on from the bladder 
to the duodenum with all the above symptoms, and yet cause no material 
stoppage of bile. In a large number of cases, however, its presence in 
the common duct is followed by more or less complete retention, which 
reveals itself by the vomit (if it continue) ceasing to be bilious, by the 
stools acquiring a pale clay color, by the urine in from twelve to twenty- 
four hours becoming tinged with bile, and by the development a little later 
of general jaundice. The supervention of jaundice, after such symptoms 
as have been detailed, is almost pathognomonic of the passage of a biliary 
calculus, or at all events of a foreign body, along the common duct. The 
diagnosis cannot, however, be regarded as positive, unless the calculus be 
discharged per anum. And hence, in all cases of suspected hepatic colic, 
it is important to examine the feces carefully from day to day. This 



708 



DISEASES OF THE DIGESTIVE ORGANS. 



should be done by diluting them with water, and passing them through a 
sieve with sufficiently small meshes to retain any small solid bodies which 
may be present. If the pain and other symptoms continue for some 
little time, more or less inflammation is likely to arise at the seat of dis- 
ease ; and tenderness and fulness may then come on, together with more 
or less febrile disturbance. And even after the escape of a calculus, such 
pain and fever, and even jaundice, may continue for some little time. 
The passage of one biliary calculus is often, if not generally, succeeded at 
irregular intervals by the passage of others — the later attacks, however, 
being as a rule both milder and of shorter duration than the first. This 
repetition of similar attacks is a further indication of the nature of the 
patient's malady. It may be added that the passage of biliary gravel, 
which has been sometimes discovered in the feces in large quantities, and 
inflammation of the neck of the gall-bladder, may present many of the 
symptoms which attend the passage of calculi. 

The consequences of the arrest of gall-stones in the small intestine have 
been described under the head of intestinal obstruction ; those of their 
long-continued or permanent retention in the common duct will be con- 
sidered under that of obstruction of the hepatic ducts. 

Treatment. — The general treatment of gall-stones is very unsatisfactory ; 
we can neither dissolve them nor remove them ; nor if they have once 
formed can we prevent them from becoming larger. And even as regards 
prophylaxis, all that can be said is that those whom we believe liable to 
them should eschew all such habits as seem likely to engender them. They 
should live wholesomely and abstemiously, and take a sufficiency of exer- 
cise daily. The habitual use of alkaline waters has been recommended, 
but the evidence in favor of their virtues is altogether valueless. For the 
paroxysm of hepatic colic, our main reliance must be placed upon morphia 
or opium, given in sufficiently large doses, and sufficiently frequently, either 
by the mouth or hypodermically, to relieve the patient's sufferings. Bella- 
donna has also been largely recommended, mainly with the object of re- 
laxing spasm, and so aiding the onward passage of the stone ; but it is 
certainly not so beneficial in its effects as opium. The inhalation of chlo- 
roform, short of producing insensibility, often affords signal relief. To 
assuage the vomiting, Dr. Prout long ago recommended the use of copious 
draughts of- warm water, containing from one to two drachms of carbonate 
of soda to the pint. This practice is still largely followed, and believed 
to be efficacious. In addition to these remedial measures, the warm bath, 
hot fomentations to the epigastrium, and counter-irritants may generally 
be employed with advantage. 



XI. OBSTRUCTION OF THE HEPATIC DUCTS. 

Causation Obstruction of the hepatic ducts is an incident of frequent 

occurrence, and of more or less importance, in a large number of the 
morbid conditions of the liver, which have already been discussed ; it is 
also the most frequent cause of long-continued and intense jaundice, if 
not actually the most frequent cause of jaundice ; and on these grounds 
demands some special consideration. The causes of obstruction are, in 
some cases, inflammatory thickening of the mucous membrane of the ducts, 



OBSTRUCTION OF THE HEPATIC DUCTS. 



709 



or accumulation of inspissated mucus or other kinds of inflammatory exu- 
dation ; in some the presence of stricture ; in some the growth of polypoid 
tumors ; in some the impaction of calculi or other foreign bodies. In other 
cases they are to be sought in inflammatory infiltration of the tissue of the 
lesser omentum or of Glisson's capsule, or in the development in these 
situations of syphilitic, carcinomatous, or other growths involving or com- 
pressing the ducts. Further, tumors springing from the stomach, pancreas, 
or neighboring parts, and aneurisms may press upon the common duct and 
obstruct its channel. 

Morbid anatomy Obstruction may take place in any of the ducts at 

any part of their course; and the effects on the ducts behind the impedi- 
ment, and on the liver-substance with which they are in relation, will be 
the same in kind wherever the obstruction is situated ; the bile becomes 
arrested in its flow and altered in character, the implicated ducts undergo 
dilatation and' other changes, and the liver-cells whose products they 
receive become jaundiced, fatty, and sometimes disintegrated. 

If complete obstruction take place in the common duct, the dilatation 
of ducts which, ensues is almost universal; the common duct not unfre- 
quently attains the size of the duodenum, and the ducts ramifying through- 
out the liver acquire proportionably large dimensions. The condition of 
the gall-bladder under such circumstances varies ; sometimes it shrinks or 
shrivels up, sometimes it retains pretty nearly its normal bulk, sometimes 
it becomes, like the rest of the excretory apparatus, enormously distended. 
The consequences of obstruction, as respects the biliary fluid, are that it 
generally gets thin and watery, and at the same time of a dark -green or 
brown color ; but it may also become turbid from admixture with mucus 
or pus ; sabulous from the deposition of solid matter — pigment, or choles- 
terine ; grumous from containing blood; or, when the bile ceases to form 
or to flow, transparent, colorless, and viscid. The last kind of fluid may 
be met with in the gall-bladder when, after closure of the cystic duct, it 
dilates (as occasionally happens) into a mucous cyst. The consequences, as 
regards the walls of the ducts, are also very various. In most cases they 
become thickened ; but in some they become attenuated ; in some inflam- 
mation with excess or modification of secretion takes place, in some 
ulcerative destruction. In the last case, perforation of the common duct 
may occur, with the development of an abscess in its vicinity, or rupture 
into the peritoneum; or more or less general destruction of the walls of the 
bile-ducts may ensue with the formation in their place of irregular biliary 
channels, bounded by the eroded hepatic tissue, and communicating, it 
may be, with branches of the portal vein. Such channels may be con- 
verted into branching abscesses. The effects of obstruction, on the liver 
generally, are, in the first instance, gradual and uniform increase of bulk, 
which may be maintained for several months ; and then gradual atrophy, 
the organ however not so much shrinking in all its dimensions as becoming 
wrinkled, thin, and flabby in consistence. The hepatic texture becomes, 
soft, loose, and cedematous (yielding on pressure a considerable quantity 
of thin greenish fluid) and jaundiced, or before long of a dark-greenish 
hue. On microscopic examination, the hepatic cells are usually found 
more or less deeply bile-stained, and often containing granular pigment 
and oil-globules. In some cases the cells after a time undergo degenera- 
tion ; and all that remains of the hepatic texture may then be the frame- 
work of connective tissue, vessels, and the like, together with a greater or 
less abundance of free oil-globules, granules of precipitated pigment, and 



710 



DISEASES OF THE DIGESTIVE ORGANS. 



cell-nuclei. The tissues moreover usually yield an abundance of leucine 
and tyrosine. 

It lias been assumed throughout the foregoing account that the obstruc- 
tion is complete and permanent. It need scarcely be added that obstruc- 
tions are often merely temporary, that whether temporary or permanent 
they are not unfrequently incomplete, and that under either of these cir- 
cumstances there will be more or less important modification in the pro- 
gress and consequences of the secondary pathological lesions. 

Symptoms and progress — It is always important, for the sake both of 
prognosis and of treatment, but often quite impossible, to determine the 
exact cause of obstructive jaundice. Our diagnosis in each case must rest 
on a careful consideration of its history and progress and on a close inves- 
tigation of the phenomena which come under our immediate observation. 
It is not, however, so much with this subject that we have now to deal as 
with the special symptomatic consequences of obstruction. - These, which 
have already been pretty fully considered, may be divided mainly into 
those dependent on absence of bile from the alvine evacuations, those due 
directly to the changes going on in the liver, and those arising from the 
accumulation of bile and effete matters in the blood. 

The consequences of the absence of bile from the bowels have been 
sufficiently discussed. 

Alteration in the bulk of the liver is a sign of considerable value. Its 
primary enlargement is indicated on the one hand by the gradual rise of 
the hepatic dulness into the chest, on the other hand by the gradual emer- 
gence of its lower edge from under the ribs and its extension for two or 
three inches below its normal level. If the gall-bladder also undergo dis- 
tension, it may generally be readily recognized as an elastic or fluctuating 
swelling coming out from beneath its accustomed notch. In rare cases 
the distended common duct has itself been felt as a fluctuating tumor. 
When the later atrophic changes set in the enlargement of the liver ceases, 
and the organ undergoes slow diminution in bulk ; but this change reveals 
itself less by general shrinking than by diminution of thickness — the free 
edge often becoming peculiarly thin, so that, if the abdominal walls be 
flaccid and spare, it may often be readily grasped between the finger and 
thumb. Some degree of fulness, weight, tenderness, or pain is not unfre- 
quent in the situation of the liver, during the progress of its enlargement ; 
especially, of course, if inflammatory changes supervene. 

The jaundice of complete obstruction is generally very intense. It first 
reveals itself by the presence of bile-pigment in the urine at the end of 
from twelve to thirty-six hours after bile has ceased to flow into the bowels. 
Yellowness of the conjunctivae and skin usually supervenes in the course 
of the third day. If the obstruction continue, the intensity of the jaundice 
rapidly increases, and after a time tends to assume a greenish or brownish 
tint. The color is liable to variations of intensity even when no discharge 
of bile into the bowels takes place, and by no means necessarily increases 
with the duration of the case ; indeed, it not unfrequently happens that it 
undergoes manifest diminution during the later periods of the disease. 

It is chiefly in jaundice from obstruction that we may look for the occur- 
rence of many of those additional phenomena which have already been 
adverted to, such as yellow vision, itching, cutaneous eruptions, and pete- 
chial and other forms of hemorrhage; and it is with this alone that xan- 
thoma has any connection. As a rule, there is no elevation of temperature ; 
and there is no necessary affection of the tongue or loss of appetite. 



OBSTRUCTION OF THE HEPATIC DUCTS. 



711 



It is almost needless to say that, in those cases in which the obstruction 
is temporary only, in those in which the obstruction of the main duct is, 
and remains incomplete, and in those in which (as in hypertrophic cir- 
rhosis) the impediment to the escape of bile involves some of the minuter 
tubes only, the symptoms will vary more or less widely from those which 
have just been detailed ; especially the evacuations will probably still con- 
tain bile, the liver will undergo little or no enlargement, the jaundice will 
be slight, and the other symptoms which associate themselves with these 
conditions will be developed slightly or late, or not at all. 

The duration of life in cases of jaundice with complete obstruction 
varies a good deal. In some cases the patient dies in the course of a few 
weeks ; in some he survives for periods varying between six and twelve 
months ; while occasionally life is prolonged to two, three, or more years. 
The causes of death also are various. Sometimes death is due to rupture 
of the hepatic or common duct, or of the gall-bladder, with consequent peri- 
tonitis ; sometimes to the supervention of hepatic inflammation with suppura- 
tion and some one or other of their results ; sometimes to intestinal or other 
hemorrhage ; sometimes to so-called ' biliary toxaemia ;' most frequently, how- 
ever, it results from gradually increasing emaciation and debility. Further, 
patients enfeebled by this disease are very apt to be attacked with pneumonia, 
dysentery, dropsy, or other complications, and to be thus carried off. In some 
cases, recovery takes place even after complete obstruction has lasted for a 
considerable length of time ; the indications of this event being the reappear- 
ance of bile in the feces, the gradual disappearance of pigment from the 
skin and urine, and, in association therewith, general improvement in the 
patient's health. 

Treatment In the treatment of jaundice from obstruction, our first 

object should, of course, be to remove the mechanical obstacle to the escape 
of bile from the liver. It need scarcely be said, however, that this can 
never be effected but by indirect measures, and in a large proportion of 
cases never effected at all. But, in reference to this subject, we must 
refer the reader to those articles which deal with the various conditions to 
which obstruction may be due. The question we have here specially to 
consider is — How shall the jaundice and the consequences it entails be 
best treated ? Unfortunately, we can do little, and that little is mainly 
hygienic. The patient's bowels should be regulated, if necessary, by mild 
laxatives ; the functions of the kidneys and of the skin (by which emunc- 
tories bile is now almost solely eliminated) should be promoted by the use 
of diluents, diuretics, warm clothing, and warm baths, with rubbing or 
shampooing ; his appetite should be sustained and his gastric digestion 
improved, if need be, by vegetable tonics or stomachics, with which the 
carbonates of the alkalies may often be beneficially combined; his general 
health should be maintained, partly by the exhibition of vegetable tonics 
and iron, partly by the habitual use of nutritious unstimulating food from 
which fatty matters and alcohol are, as far as possible, excluded, partly 
by attention to hygienic conditions, more especially to warm clothing, the 
avoidance of chills or sudden vicissitudes of temperature, change of scene, 
moderate exercise, and early hours. Of particular remedies, it may be 
observed that Frerichs recommends lemon-juice as a valuable diuretic in 
these cases, and that Dr. G. Harley advocates the use of inspissated ox-gall 
in gelatine capsules, to be given in doses of from five to ten grains two or 
three hours after each meal. It need scarcely be added that when com- 
plications arise — gastric catarrh, diarrhoea, hemorrhage, or head-symptoms 



712 



DISEASES OP THE DIGESTIVE ORGANS. 



— they will probably need each its appropriate treatment. In those cases 
in which the gall-bladder becomes excessively distended, the question as 
to the propriety of puncturing it may arise. The operation is obviously 
one not to be lightly entertained, or to be performed without the most 
ample precautions. 



XII. JAUNDICE WITHOUT OBVIOUS OBSTRUCTION OF 

DUCTS. 

Causation. — The varieties of jaundice here referred to are more partic- 
ularly those which occur in the specific febrile disorders, such as yellow 
fever, ague, relapsing fever, and pyaemia. It is possible, too, that under 
the same head must be included the jaundice which occasionally attends 
pneumonia, rheumatism, snake-bites, phosphorus-poisoning, and those other 
morbid conditions of the liver in which the secreting cells are directly in- 
volved. The jaundice which is said to arise under the influence of strong 
mental disturbance, and that of new-born babes, may possibly also be 
placed in the same class. It must be remarked, however, that there is 
still considerable uncertainty in respect of the intimate pathology of the 
jaundice attending these various affections ; it is very probable that obstruc- 
tion of the smaller ducts* or, as Virchow holds, catarrhal obstruction of 
the intestinal portion of the common duct, may eventually be proved to 
be the cause of jaundice in some of them ; there seems little doubt that 
in others it is actually due to changes going on in the coloring matter of 
the blood ; and it is possible that in some of them it may be the conse- 
quence, as Frerichs holds, of an abnormal diffusion of bile, arising in some 
alteration in the supply of blood to the liver, and defective metamorphosis 
or consumption of bile in the blood ; and in some, as Dr. Murchison 
believes, of excessive reabsorption of bile with or without excessive 
secretion. 

Morbid anatomy In most of the cases here referred to the liver is found 

post mortem to be pale and anoamie, and soft or flabby, and the hepatic 
cells either quite normal, or, as especially in phosphorus-poisoning, unusu- 
ally granular or studded with droplets of oil ; in some the generally pallid 
tissue presents patches of still more marked pallor, which are often separ- 
ated from the surrounding parts by wide but irregular zones of slight con- 
gestion. The appearances, as a rule, are certainly not very striking, and 
scarcely indicative of serious hepatic disease. 

Symptoms The jaundice is almost without exception very slight ; it 

creeps on gradually ; it does not attain any intensity in the skin ; and the 
pigment passed with the urine is in small quantity. Moreover, the motions 
almost always still contain bile. There is no doubt that in many of these 
cases the symptoms which the patient presents are extremely grave. Yet 
there is no good reason to believe that as a rule they are due in any important 
degree to the hepatic disorder ; for while the grave symptoms are usually 
such as characterize the disease which the jaundice complicates, those cases 
in which jaundice appears are not generally more serious than those from 
which it is absent, and the jaundice does not as a rule bring with it any 
specific symptoms. 

Treatment The forms of jaundice now under consideration seldom call 



MALIGNANT JAUNDICE. 



713 



for special treatment. Their presence, however, may furnish a hint as to 
the desirability of employing laxatives, and promoting., the action of the 
skin and kidneys. 



XIII. MALIGNANT JAUNDICE. {Yellow Atrophy of the Liver.) 

Definition There is one form of disease in which jaundice is associated 

with a remarkable group of symptoms, which for convenience, if not on 
other grounds, may be separated from the cases which have just been con- 
sidered ; it is that which is sometimes termed malignant jaundice, and to 
which Rokitansky has given the name of < yellow atrophy of the liver.' 

Causation. — Cases of malignant jaundice have been observed chiefly, if 
not solely, in adults, and in women far more frequently than men. More- 
over, in a large proportion of cases, the patient has been attacked during 
pregnancy. It is also a remarkable fact that the onset of the disease ap- 
pears to have often been determined by some sudden and intense mental 
emotion. Among other assigned causes may be enumerated syphilis, 
typhus, and miasm. 

Symptoms and progress Malignant jaundice frequently comes on 

without premonitory signs ; but in a considerable number of cases it is 
preceded for a few days, or even for a few weeks, by slight gastro-intestinal 
catarrh, with which probably, sooner or later, some degree of jaundice is 
associated. Among the first symptoms which usually arise to indicate the 
gravity of the attack are vomiting, and especially the vomiting of coffee- 
ground fluid due to gastric hemorrhage, intense headache, irritability, and 
restlessness. To these soon succeeds delirium, which is sometimes low 
and muttering, sometimes noisy, and frequently violent and maniacal. The 
patient's manner is agitated, there is generally more or less tremulousness 
of limbs, and in a large proportion of cases convulsions soon manifest them- 
selves. These may vary in character; they may be general or local; and 
may present the features of simple rigors, or assume an epileptiform or 
tetanic form. After a short time, the condition of delirium or convulsion 
passes into one of quietness and stupor, which gradually deepens into pro- 
found coma, usually attended with dilated inactive pupils and stertorous 
breathing. But, besides the remarkable combination and sequence of 
symptoms here enumerated, other phenomena present themselves which 
are of considerable significance and importance in reference to diagnosis. 
The pulse during the earlier period of the disease, or that of excitement, 
is characterized by remarkable and sudden variations in frequency, but is 
generally abnormally quick; with the supervention of coma, however, it 
gets more uniformly rapid, and at the same time more and more feeble, 
until probably it can be no longer felt at the wrist. The tongue soon be- 
comes coated, and generally before long assumes the typhoid character; it 
gets dry and brown or black, and sordes accumulate upon the teeth. There 
is often some uneasiness and tenderness in the hepatic region ; and in ad- 
dition, it can often be determined by careful examination that there is a 
gradual diminution in the area of hepatic dulness. The bowels usually are 
confined ; and the motions passed in the course of the disease present a 
gradual diminution, and at length, it may be, total absence, of biliary color. 
The urine probably is secreted in normal quantity, and acid ; but it becomes 
jaundiced in a greater or less degree, urea and phosphate of lime diminish, 



714 



DISEASES OF THE DIGESTIVE ORGANS. 



and sometimes wholly disappear, to be replaced by leucine, tyrosine, and 
extractive matters, which, when the urine cools, sometimes form a peculiar 
greenish-yellow sediment. The skin is usually cool and dry. The jaundice, 
which sometimes precedes, sometimes follows, and sometimes appears 
simultaneously with, the other initial symptoms of the disease, increases 
in depth with the duration of the malady, but rarely, if ever, attains any 
high degree of intensity. There are yet two other features of striking 
importance : the one is the total absence of febrile temperature ; the other 
a general tendency to hemorrhage. The latter shows itself by hsemate- 
mesis, by the appearance of petechias and bruise-like extravasations beneath 
the skin, or by more or less profuse discharges of blood from the nose, 
bowels, or other mucous surfaces. 

The most striking phenomena in the clinical aspect of malignant jaun- 
dice are, the combination of slight jaundice with grave cerebral disturb- 
ance, hemorrhage from and into various organs and tissues, profound 
change in the composition of the urine, absence of fever, and the almost 
invariably fatal issue of the disease. Death may occur within twelve or 
twenty-four hours, but generally supervenes between the second and fifth 
day, and is rarely delayed beyond a week. 

Morbid anatomy. — In all typical cases of the disease the post-mortem 
conditions are remarkable and characteristic. The most obvious change 
is manifested by the liver. This may be of natural size, but is usually 
shrunk to half or even one-third of its normal bulk — its surface being then 
wrinkled and flabby. On section it is found to be of a nearly uniform 
pale yellow color, with little or no indication of the constituent lobules, or 
evidence of vascular injection. Frerichs says that in some cases the 
lobules are separated from one another by a dirty grayish-yellow sub- 
stance. The bile-ducts and gall-bladder usually contain either colorless 
mucus, or a thin fluid only very slightly tinged with bile. On micro- 
scopic examination, the hepatic cells are found to have disappeared more 
or less completely — in some cases not one is discoverable; and in their 
place may be observed either simple granular matter, or this intermingled 
with oil-globules and precipitated bile-pigment. Leucine and tyrosine 
also may sometimes be recognized in the hepatic substance and hepatic 
veins. There is usually some enlargement of the spleen. The only other 
morbid phenomena of importance are : occasional fatty change of the 
glandular epithelium of the kidneys ; extravasations of blood (usually 
petechial) beneath the surface of the peritoneum, pleurae, and peri- 
cardium, in connection with the gastro-intestinal and other mucous mem- 
branes, and occasionally in the substance of the lungs, liver, spleen, and 
kidneys ; and the presence in the blood (which does not as a rule display 
any change visible to the naked eye) of large quantities of leucine and 
urea. 

What the nature of the malady under consideration may be, is by no 
means satisfactorily established. By some it is regarded as a primary 
disease of the liver. Frerichs, who (following Bright) takes this view, 
looks upon it as a parenchymatous inflammation of the organ, attended 
with little exudation, but with obstruction to the passage of blood through 
the vascular network at the periphery of the lobules, and consequent de- 
generation and death of the hepatic cells. According to this view, the 
jaundice and other characteristic symptoms of the disease are secondary 
to the hepatic lesion. Some, on the other hand, look upon the hepatic 
affection as the consequence of some general blood-disease, due either to 



DISEASES OF THE PANCREAS. 



715 



| the absorption of some noxious chemical substance, or to the presence of 
I a poison of organic origin having some affinity with those of the infectious 
fevers, or of pygemia. In the latter point of view some of the graver 
symptoms would be referable to the primary disease of which the hepatic 
disorder is a consequence ; but others might still be attributable to the 
morbid condition of the liver. It would not be difficult to adduce plausi- 
ble arguments either against or for either of these hypotheses. We may, 
! however, point out that while, on the one hand, there is nothing in the 
I clinical phenomena of these cases to indicate their inflammatory origin ; 

there is, on the other hand, ample proof, from the occasional supervention 
| of the symptoms of malignant jaundice in cases of occlusion of ducts, that 
. extensive destruction of the secreting structure of the liver, with suppres- 
sion of bile, is fully competent to induce all the phenomena of the disease 
under consideration. We must confess, indeed, that, while not quite com- 
I mitting ourselves to the inflammatory origin of the hepatic changes, we are 
j disposed to regard the disease as primarily hepatic. 

Treatment Nothing can well be less satisfactory than our knowledge 

in reference to the treatment of malignant jaundice. Active purgation 
j has been recommended, especially in the early stage ; it is difficult, how- 
ever, to understand why. Again, those who look upon the disease as of 
inflammatory origin advocate the local abstraction of blood, and other 
antiphlogistic measures, during the inflammatory stage. But unfortu- 
nately this, if it exist at all, exists only during that preliminary period in 
which there is ndthing to distinguish cases of malignant jaundice from 
cases of catarrhal affection of the biliary ducts. Considering that in this 
disease there is a large accumulation of effete matter in the blood, on 
which it seems probable that some of the grave symptoms are dependent, 
there are grounds for the employment of diuretic and diaphoretic meas- 
ures. In the absence of more obvious indications, we must either do 
nothing, or treat the more prominent symptoms : that is, so far as we are 
able, check vomiting, arrest hemorrhage, overcome constipation, promote 
.the action of the skin and kidneys, soothe during the stage of excitement, 
and during that of stupor and coma and failing strength employ counter- 
irritants and stimulants. 



XIV. DISEASES OF THE PANCREAS. 

A. Introductory remarks Very little of clinical value is known about 

the diseases of the pancreas. This is due : partly to the comparatively 
small size and deep situation of the gland ; partly to the fact that its 
functions have much in common with those of the salivary and duodenal 
glands, and even with those of the liver itself; but chiefly perhaps because 
it is rarely affected excepting secondarily or in association with diseases 
of neighboring organs. 

In reference to the diagnosis of pancreatic disease, we must recollect : 
that this organ is situated in front of the aorta and behind the stomach, 
deep in the epigastric region, and on the level of the first lumbar vertebra ; 
that any tumor which may be developed in it will be discoverable in this 
situation only (a situation however which may be equally affected by aneu- 
risms of the aorta or coeliac axis, or by tumors involving the posterior wall 



716 



DISEASES OF THE DIGESTIVE ORGANS. 



of the stomach, or originating in the retro-peritoneal glands), and will prob- 
ably be immovably fixed there ; and that any pain and tenderness which 
may attend its lesions will probably be referred to the depth of the epigas- 
tric region and to the back, in the situation of the upper lumbar and lower 
dorsal vertebras. We must also recollect that the function of the organ 
is to secrete a large quantity of fluid, which differs little from ordinary 
saliva in either its chemical composition or its office, and is an important 
agent in the emulsification of fat, in the conversion of starch into dextrine 
and sugar, and in the reduction of albuminous matters into a form favor- 
able for assimilation. It may therefore be reasonably believed that the 
retention or suppression of the pancreatic fluid will be attended with more 
or less serious impairment of nutrition ; and, if the food contain much 
starch or fat, with the unwonted appearance of starch or fat in the evacu- 
ations. The abundant discharge of fat by stool, indeed, has been not 
unfrequently noticed in cases in which the pancreas has been seriously 
diseased. 

B. Hypercemia and inflammation. — Of these conditions but little can 
be said. They are occasionally recognized post mortem, but for the most 
part in cases where no suspicion of pancreatic disease was entertained 
during life. Abscesses are sometimes discovered in the gland, and occa- 
sionally large abscesses ; but they are usually small and of pysemic origin. 
Catarrhal inflammation of the duct is probably not uncommon in connec- 
tion with the same affection of the common hepatic duct, and may, like 
that, lead to temporary or even permanent obstruction.* In chronic ulcer 
of the stomach the subjacent pancreas not unfrequently becomes impli- 
cated in the course of the extension of ulceration ; and thus its eroded 
substance may after a time form the floor of the ulcer. 

C. Morbid growths The pancreas is often the seat of such formations; 

but they are rarely, if ever, of primary origin within it. They are some- 
times a consequence of the generalization of malignant tumors, but are 
much more frequently due to extension of disease from the stomach, retro- 
peritoneal glands, or peritoneum. It is, however, in carcinoma of the. 
pyloric extremity of the stomach that the pancreas most frequently becomes 
involved. Of the several varieties of malignant disease to which it is 
liable, scirrhus is the most common ; but the encephaloid, colloid, and 
melanotic forms have each been met with. 

D. Calculi are occasionally discovered in the pancreatic ducts, and more 
especially in the principal duct. They have the same chemical and other 
characters as other salivary calculi — consisting mainly of phosphate of 
lime with some animal matter, and varying from minute granules up to 
the size of a filbert. When small they are sometimes present in vast 
numbers ; when large they are usually solitary, and more or less completely 
obstruct the duct in which they lie. 

E. Obstruction of the pancreatic ducts When these channels get 

blocked up, whether by calculi or stricture, or by their compression by, or 
involvement in, malignant or other growths, the ducts behind undergo 
gradual dilatation from the accumulation of secretion within them. The 
chief enlargement occurs in the principal duct, which becomes elongated 
and tortuous, irregular in form, and sometimes sufficiently dilated to admit 
the finger. The secondary ducts also become dilated, but in a less degree ; 
and the whole organ consequently increases in bulk, and on section appears 
at first sight to be made up of a congeries of cysts — the secreting tissue be- 
tween them being more or less atrophied. Solitary cysts, apparently due 



DISEASES OF THE PANCREAS. 



717 



to the dilatation of obstructed ducts of small size, are occasionally dis- 
| covered in the glands which are in other respects healthy. Their only 
pathological importance arises from the fact that they may, from their size 
and situation, be readily mistaken for tumors or cysts of much more serious 
import. They may attain the size of an orange. 

F. Symptoms and treatment — It would be a waste of time to discuss 
! the diagnosis of the various lesions which have just been passed in review ; 
j the special phenomena which must be looked for as indicative of pancreatic 
| disease have already been sufficiently considered ; and for the recognition 
of additional features special to each variety of lesion, the practitioner 
must be guided by his general knowledge of pathology and of the pathology 
of the pancreas. In the great majority of cases pancreatic disease will 
doubtless remain undetected during life. 

It would be equally a waste of time to enter upon the discussion of the 
treatment of pancreatic affections. 



718 



DISEASES OP THE GE N IT O- URINARY ORGANS. 



CH APTEE VI. 

DISEASES OF THE GENITO-UEINARY ORGANS. 
Section I. — DISEASES OF THE KIDNEYS. 

I. INTRODUCTORY REMARKS. 

General Physiological and Pathological Considerations. 

The urinary organs comprise the kidneys, ureters, bladder, and urethra. 
The diseases of all these parts are of high interest to the physician ; but 
those of the kidneys and ureters come more especially under his observa- 
tion and treatment, and it is mainly to them, therefore, that attention will 
be directed in the following pages. 

The sole function of the kidney is to separate from the blood, in asso- 
ciation with water, a number of effete, waste, and surplus matters which 
are constantly being added to the blood from various sources. But the 
urine, as it escapes from the urethra, contains in greater or less proportion 
certain additional matters — mucus and the like — which are yielded to it 
by the various mucous surfaces over which it passes, and by the glandular 
organs which open upon them. 

The urine, thus constituted, varies in composition within wide limits, 
even in health. In disease, where the nutritive and destructive processes 
are variously modified, and where the functional activity of important 
organs is in different degrees diminished, impaired, or exalted, the com- 
position of this fluid undergoes still greater variations ; and, indeed, there 
are some cases (as for example that of diabetes) in which, the kidneys 
remaining sound, the nature of the disease under which the patient labors 
is revealed almost solely by the peculiarities which the urine presents. 
But especially the composition of the urine is largely and importantly 
modified by diseases of the urinary organs, which tend on the one hand to 
impede the discharge from the blood of the proper urinary constituents, 
and on the other hand to add to the urine matters which are wholly foreign 
to its normal constitution. It is obvious, therefore, that the careful inves- 
tigation of the urine may be expected to throw important light, not only 
on the varying processes connected with healthy nutrition, but also on the 
pathology of many of those morbid conditions in which the kidneys are not 
distinctly implicated, and above all on the nature of the diseases of the 
kidneys themselves and of the several organs in relation with them. 

But again, when the urinary organs are the seat of disease, and oppose 
(as they then generally do) a more or less complete obstacle to the elimi- 
nation of urea and other such products from the blood, it is clear that this 
fluid must soon become surcharged with effete and presumably injurious 
matters of a specific kind, and that we must, therefore, expect specific 
morbid consequences sooner or later to ensue. 



URINE IN HEALTH AND DISEASE. 



719 



It is also clear that many diseases of these organs must be attended with 
both local and general indications and symptoms which are totally inde- 
pendent of the functional derangements which are associated with them — 
local phenomena, such as pain and tumor ; general phenomena, such as 
inflammatory fever and some forms of cachexia. 

The morbid phenomena, therefore, which are associated with, and result 
from, diseases of the kidneys may be properly and conveniently divided : 
first, into those which are special to these organs and depend directly on 
the impairment or perversion of their normal functions ; and, secondly, 
into those which in a certain sense are common to these and other similarly 
affected constituent portions of the body. 

In accordance with the foregoing observations, we propose to give a brief 
account : first, of the composition of the urine in health and disease ; 
second, of the specific consequences of the retention of urea and other such 
matters in the blood ; and, third, of the non-specific morbid phenomena 
which attend and characterize lesions of the urinary organs. 

A. Characters and Composition of the Urine. 

The urine is a transparent, limpid, straw- or amber-colored fluid, of 
saline taste, and for the most part of acid reaction, which deposits, on 
standing, a filmy cloud of mucus, and occasionally an opaque, reddish, 
powdery sediment. Its acidity increases for a few days with exposure to 
the air, and at the same time urates, uric acid, and oxalates are deposited. 
Then it undergoes putrefaction, becomes alkaline and ammoniacai ; earthy 
matters, including crystals of triple phosphate, fall; and bacteria and 
torulse make their appearance in it. 

The quantity passed in twenty-four hours fluctuates within wide limits : 
it may, however, be reckoned usually at between two and three pints in 
the adult, but may range from one to four pints. The specific gravity also 
presents a wide range: it commonly lies between 1015 and 1025, but tem- 
porarily may fall to 1005 or less, or rise to upwards of 1030. The acidity 
which, when the urine is emitted from the bladder, is an almost unfailing 
characteristic of it, is liable to a good deal of variation of intensity ; and, 
indeed, as Dr. W. Roberts shows, that which is secreted an hour or two 
after meals is generally alkaline, although its alkalinity is commonly 
masked by its admixture in the bladder with acid urine already there or 
subsequently added to it. The acidity depends mainly on the presence of 
acid phosphates and urates, and in some degree also on traces of lactic, 
oxalic, and other acids. 

The degree in which the specific gravity of urine exceeds that of dis- 
tilled water depends on the solid matters — the special urinary constituents 
— which are contained in it. The proportion which these hold to the 
watery constituent may be approximately estimated, according to Trapp's 
formula, by doubling the last two figures of the number which indicates 
the specific quantity. Thus 1000 parts of urine with a specific gravity of 
1015 contain 30 parts of solids; and 1000 parts of urine with a specific 
gravity of 1025 contain 50. Hence the amount of solid matter in healthy 
urine usually varies from three to five per cent. It is generally, however, 
far more important to know the actual amount of solid matter that is 
passed daily than the ratio which solid matter holds to the very variable 
quantity of water with which it is mixed. This knowledge can be gained 
by collecting and mixing all the urine passed in the course of tw r enty-four 



720 DISEASES OF THE GEN] TO - URINARY ORGANS. 

hours, and then examining quantitatively a measured portion of its bulk, 
or, more readily though less accurately, by the method above given. 

The solid matters of the urine are very numerous ; and they vary 
largely, both in the relative proportions in which they are excreted and in 
their aggregate amount. The urea especially is remarkably modified by 
age, sex, diet, and other circumstances, so that the amount which may be 
taken as the average may be halved or doubled independently of any im- 
pairment of health. The following table is designed to show at a glance 
the relative proportions of the chief constituents contained in an average 
specimen of the urine of an adult, and the total quantities of each which 
might in such a case be discharged in twenty-four hours. The specific 
gravity is assumed to be 1025, and the temperature 32° : — 



Urinary Constituents. 


Percentage 
composition. 


Daily aggregate 
in grains. 


Urea CH 4 N 2 0 

Uric acid C 5 H 4 N 4 O s 

Kreatinine C 4 H 7 N 3 0 ..... 
Hippuric acid HC 9 H g N0 3 .... 
Pigment, mucus odorous j Extractive . 
matters, xanthine, &c. J 
Total organic matters ..... 

Sulphuric acid . . . . • 
Phosphoric acid ..... 


95-000 

2-500 
• -042 

•075 

•075 

•600 

3-292 

•500 
•150 
•250 
•175 
•600 
•018 
•015 

1-708 


19000-0 

500-0 
8-5 
15-0 
15-0 

120-0 

658-5 

100-0 
30-0 
50-0 
35-0 
120-0 
3-5 
3-0 

341-5 




100-000 


20000-0 
or 45^ oz. 



The variations in the quality and quantity of the urine in health are so 
wide that it is often extremely difficult, and sometimes impossible, to be 
certain, from the examination of this fluid alone, whether it should be re- 
garded as healthy or morbid. When matters are added to it which are 
wholly foreign to its composition, and cannot be ascribed to the influence 
of special articles of food or other substances which have been received 
into the blood, no doubt as to its morbid character can be entertained. 
Again, when, independently of external conditions and habits of life, the 
urine habitually deviates largely from the mean, whether in the direction 
of excess or diminution, as regards either its total bulk or the amount of 
any of its more important constituents, no doubt as to its unhealthiness is 
possible. And again, when sediments form habitually, even though the 
sedimentary matters be normal constituents of the urine, and the chemical 
composition of the urine itself reveals no appreciable departure from health, 
the unhealthy condition of the secretion is indisputable. 

In the following account of the urine, which is intended to be mainly 
pathological, and from which, therefore, some physiologically important 
constituents will be omitted, it will be convenient, after briefly adverting 



URINE IN HEALTH AND DISEASE. 



721 



to the physical characters of morbid urine, to embody such physiological 
and chemical remarks in reference to its normal constituents as are neces- 
sary for a clear comprehension of the pathology of this excretion. 

1. Physical characters of morbid urine The quantity of urine passed 

differs very largely in different diseases. In some general affections, as 
cholera and collapse — sespecially collapse connected with lesions of the 
abdominal organs — the urine is absolutely suppressed. In most febrile dis- 
orders, and in inflammations, it is diminished. In other cases, on the 
contrary, as after hysterical paroxysms, in the condition known as diabetes 
insipidus, and especially in diabetes mellitus, it becomes profuse. Again, 
the urine is generally greatly diminished when acute nephritis is present ; 
it may even be temporarily suppressed from this cause. On the other 
hand, in chronic renal disease it is often largely increased. Its discharge 
is occasionally arrested in consequence of obstructive disease of the ureters. 
The amount of solid constituents present is not necessarily in relation with 
the quantity of urine voided. No doubt, generally, the more scanty the 
urine is, the higher is its specific gravity, and the larger the ratio which 
the solid matters hold to the water. But, on the other hand, in most 
febrile diseases there is an actual increase in the total nitrogenous consti- 
tuents, even while there is a marked diminution in the total bulk of urine 
passed ; and in the profuse urine of diabetes mellitus the quantity of solid 
matters excreted is so large that the specific gravity often rises to 1040, 
1050, or even 1060 degrees. 

The urine in disease may have the same reactions as in health ; or, on 
the other hand, it may be preternaturally acid, neutral, or alkaline. Alka- 
linity of urine may be caused by the presence either of ammonia or of 
fixed alkalies. Ammonia is due to the decomposition of urea, and appears 
only after the urine has been secreted by the kidneys. It mostly appears 
in connection with chronic inflammation of the mucous lining of the 
bladder and other parts, and the discharge therefrom of morbid mucus. 
The persistence of alkalinity due to the fixed alkalies, if it be not depend- 
ent on peculiarities of diet or medicine, is generally connected with affec- 
tions characterized by ansemia and debility. Acidity may be recognized 
by the use of blue litmus paper, which becomes red under the influence of 
acids, and alkalinity by the employment of red litmus paper, which is ren- 
dered blue by alkalies, or of yellow turmeric paper, which becomes brown. 
If the alkalinity be due to ammonia, the test-paper changed under its in- 
fluence returns to its original color on being dried. 

As regards color, smell, and the presence of turbidity or sediment, all 
that we deem it necessary to say will be incorporated in our subsequent 
account of those urinary constituents to which severally these conditions 
are mainly due. 

2. Urea (CH 4 N a O or CO(NH ) 2 ) This is by far the most abundant 

and important of the urinary solids. It is furnished by the destructive 
metamorphosis of the nitrogenous tissues of the body and elements of the 
food, and contains nearly the whole of the nitrogen which was originally 
incorporated with the substances from which it is derived. Its quantita- 

! five variations are so great during health that it is impossible, in a few 
words, to explain when and at what point such variations are to be re- 
garded as morbid. Urea is almost always largely increased during the 
febrile stages of inflammatory and febrile disorders, and in diabetes. It 
should be observed, however, that the quantity of urea eliminated is not 
in direct relation with the intensity of fever. In some febrile diseases the 
46 



! 



722 



DISEASES OF THE GENITO- URINARY ORGANS. 



urine contains no excess of urea ; and generally when the curves represent- 
ing the daily temperature and amount of urea are compared, the only cor- 
respodence between the two will be found in the early stages of the fever, 
and the longer the disease lasts the greater will be their disagreement. 
Urea being formed mainly in the liver, it is very probable that the amount 
of it eliminated is always largely influenced by the condition of the hepatic 
cells, and by the activity of the hepatic circulation. Thus, in malignant 
jaundice it diminishes, and finally disappears wholly ; in jaundice, the 
result of phosphorus-poisoning, its temporary increase is followed by marked 
diminution ; and the same remark applies to the cases of simple jaundice 
and hepatic abscess; in obstruction from gall-stones — notably during the 
period of hepatic colic — and in the subsequent atrophy of the hepatic paren- 
chyma, there is likewise a diminution. So also is it in the various forms 
of cirrhosis, and in chronic congestion of the liver. Again, urea is dimin- 
ished in nephritis and other inflammatory or structural diseases of the kid- 
neys, in anaemia, and starvation. Urea is a feeble base, and exceedingly 
soluble ; and has, therefore, under ordinary circumstances, no visible influ- 
ence over the condition of the urine. It forms no sediment, and cannot 
be detected in it except by chemical processes. Under the influence of 
the mucus of the bladder, and some other circumstances, it is readily con- 
verted, with the aid of water, into carbonate of ammonia. Urea crystal- 
lizes in white silky needles, or transparent four-sided prisms, the ends of 
which are often formed by one or two inclined planes. Such crystals may 
often be obtained by evaporating a drop of urine — especially febrile urine 
— on a glass slide. If an excess of colorless nitric acid be added to urine 
concentrated by evaporation, the mixture will become almost solid with 
crystals of nitrate of urea. These occur in rhombic prisms or plates which 
are colorless, and have a silky lustre. For the quantitative determination 
of urea various methods have been employed. The following are probably 
the best : — 

a. 1 With a solution of mercuric nitrate, urea forms a white gelatinous 
precipitate, containing one equivalent of urea to four equivalents of mer- 
curic oxide. The determination of urea by Liebig's method is based on 
this reaction. A standard solution of mercuric nitrate is prepared of such 
a strength that 10 cubic centimetres are equivalent to one gramme of 
urea. This is done by dissolving 71-5 grms. of pure mercury in nitric 
acid, and diluting with distilled water to one litre. Before urine is pre- 
cipitated by this solution its phosphates must be removed by the addition 
of a mixture of one part of cold saturated solution of baric nitrate to two 
parts of a similar solution of baric hydrate. Further, if albumen be pres- 
ent, it must be separated by boiling and the addition of a few drops of 
acetic acid. 

The process is thus performed: Two volumes of urine (say 40 c. c.) 
are mixed with one volume (20 c. c.) of the baryta solution. After shak- 
ing well, the mixture is poured on a dry filter and 15 c. c. of the clear fil- 
trate (equal to 10 c. c. of urine) removed to a small beaker. Mercurial 
solution is now slowly added from a burette so long as precipitation 
occurs. But to find the exact point when all the urea has been precipi- 
tated, it is necessary to employ some such indicator as sodic carbonate. 

1 1 gramme = 15*432348 grains — the weight of a cubic centimetre of distilled 
water at 39 *2Q F. 

1 litre = 1000 cubic centimetres = 61*024 cubic inches = 35*2754 fluidounces. 



URINE IN HEALTH AND DISEASE. 



723 



Several drops of a solution of this salt are scattered over a white plate ; 
and by means of a glass rod a little of the mixture in the beaker is brought 
in contact with the soda. So long as there is any free urea present, no 
change of color takes place at the point of contact ; but as soon as the 
mercury is in excess, a yellow precipitate results. The moment, there- 
fore, the yellow color shows itself distinctly, enough mercuric solution 
has been added. To attain an accurate result, the experiment should be 
performed a second time. Supposing 19 c. c. of the mercuric nitrate 
were required by the 10 c. c. of urine, this would indicate a percentage 
of 1*9 urea in the urine. If, however, it should be found that more than 
20 c. c. are needed, the urine for the second examination must be diluted 
by adding half as much water as the excess of mercuric nitrate solution 
employed above 20 c. c. Thus, if 30 c. c. were required in the first pre- 
cipitation, the excess is 10 c. c. ; therefore, 5 c. c. must be added to the 
10 c. c. of urine before the second precipitation. If, on the other hand, 
much less than 20 c. c. have been used, then, for every 4 c. c. less the 20, 
•1 c. c. must be deducted before calculating the percentage of urea. 

b. A very easy method for the estimation of urea depends on the 
measurement of the nitrogen evolved when the urea is decomposed by a 
hypochlorite or hypobromite. Urea yields in this way all its nitrogen, less 
8 per cent. Different apparatus are used ; but in all of them there are 
mechanical arrangements to bring about the gradual admixture of the 
urine with the test solution, and to collect the gas evolved. 5 c. c. of a 2 
per cent, solution of urea yield about 37 c. c. of gas. The collecting tubes 
are generally graduated so as to express at once without calculation the 
percentage of urea present in the urine experimented upon. The volume 
of gas given by, say, 5 c. c. of a 2 per cent, solution of urea, which is about 
37 c. c, is taken as indicating 2 per cent, of urea, and the collecting tube 
is graduated accordingly. 

3. Uric acid (C 5 N 4 H 4 0 3 ) and urates — Uric acid is derived from the 
same source as urea, and is liable to slight fluctuations in quantity under 
much the same circumstances as urea. It is readily decomposed by oxid- 
. izing agents into several less complex substances, of which urea (to which 
it contributes the whole of its nitrogen) is the most important. It may, 
in fact, be regarded as representing a stage in the conversion of albu- 
minous matter into the urea. It is exceedingly insoluble in water, and 
hence, when free in the urine, forms a crystalline deposit. It is, however, 
generally combined with a base, especially ammonia or soda, and in this 
form is much more soluble, though still liable to form a sediment. The 
main interest, indeed, attaching to the presence of uric acid and urates in 
the urine resides in the fact of their tendency to be deposited, and to take 
part in the formation of gravel and calculi. 

Free uric acid often falls during the acid fermentation taking place in 
urine which is kept ; and, when met with in fresh urine, it is generally in 
consequence of the acid reaction of that fluid being excessive. It may be 
readily recognized by the character of its crystals. These may form red- 
dish grains visible to the naked eye, but are generally microscopic objects. 
The forms which they assume are various, and depend largely on the 
quality of the urine in which they are found. They are generally lozenge- 
shaped or rhomboidal, with the angles more or less rounded, and vary in 
thickness, so as to form, on the one hand, mere films ; on the other, short 
flattened cylinders or prisms. When abundant they are often grouped 
together into stellate or variously shaped clusters. If any doubt as to the 



724 DISEASES OF THE GENITO - URIN ARY ORGANS. 

nature of the deposit exist, it may be set at rest by converting it into 
murexide. This may be done by placing a little of it in a porcelain dish, 
adding to it a drop or two of strong nitric acid, and heating the whole to 
dryness. If now, when the residue is cool, a rod dipped in caustic am- 
monia be applied to it, the beautiful purple color, characteristic of murex- 
ide, is developed. 

Urates, comprising chiefly those of ammonia and soda, are often de- 
posited in an amorphous condition, forming a powdery sediment which 
clings to the vessel, and which, from its attraction for the coloring matter 
of the urine, varies in tint from a light fawn to pink. Like uric acid itself, 
they generally precipitate in acid urine, but, unlike uric acid, they mostly 
fall in concentrated urine, especially when it becomes cool. The formation 
of uratic sediments often occurs in the urine of healthy persons, especially 
in cold weather ; it often, however, attends and indicates the presence of 
catarrh or other febrile states, or derangements of the liver or other chylo- 
poietic viscera. Amorphous urates are readily recognized by the fact that 
urine which is turbid from their presence becomes perfectly clear and 
transparent when boiled. Further, the addition of acids causes the forma- 
tion of crystals of uric acid ; and murexide may be developed by the 
method already indicated. Urate of soda is occasionally present in the 
shape of small globular concretions beset with conical spikes. These form 
in the urine while it is yet in the urinary cavities, and are liable to cause 
much irritation and to lead to the development of calculi. They have 
been especially observed in the case of children suffering from febrile 
symptoms. 

4. Xanthine (C 5 H 4 N 4 0 2 ) is a waxy, white, non-crystallizable substance, 
almost insoluble in cold water. When heated with nitric acid it dissolves 
without evolving gas ; and the residue left on evaporation acquires when 
heated with caustic potash a beautiful violet-red color. 

5. Cystine (C 3 H 7 NS0 2 , or C 8 H 5 NS0 2 ) contains 25*5 per cent, of sulphur. 
It is closely related chemically to taurine, and hence probably furnished 
by the liver. It is a neutral body, insoluble in water, and crystallizes in 
hexagonal plates. It is dissolved by the mineral acids with decomposition, 
and by the caustic alkalies without. The best way to obtain the charac- 
teristic crystals is to dissolve the cystine in a solution of ammonia and 
allow the solution to evaporate. 

6. Leucine (C 6 H 13 N0 3 ) and tyrosine (C 9 H n N0 3 ) These are formed 

;under the same conditions, and are generally associated together. Pure 
leucine occurs in white crystalline scales, has a fatty feel, and dissolves in 
water. In the impure state, as observed in urine, it often assumes the form 
of roundish concentrically marked yellowish bodies which have some resem- 
blance to fat-globules. If a small portion of leucine be saturated with 
nitric acid and the mixture carefully evaporated to dryness, it leaves an 
almost transparent residue which turns yellow or brown on the addition of 
solution of caustic soda, and yields an oily drop when reheated. Tyrosine 
forms a white, silky, glistening mass, consisting of fine needle-like crys- 
tals, which are grouped in radiating clusters and sometimes in dense 
globular masses. It gives a red coloration when boiled with Millon's 
reagent ; and a violet hue when gently warmed with sulphuric acid and 
a drop of solution of perchloride of iron is added. The urine of patients 
suffering from yellow atrophy of the liver often deposits spontaneously a 
greenish-yellow sediment consisting of crystals of tyrosine, and on evapora- 
tion yields numerous crystals of the more soluble leucine. 



URINE IN HEALTH AND DISEASE. 



725 



7. Coloring matters The normal pigments of the urine are derived 

from the coloring matter of the blood, and, according to Schunck, are two 
in number. He names them respectively urian and urianine. They are 
of a dark yellow color and syrupy consistence, have a high atomic consti- 
tution, and contain nitrogen. Their excess or deficiency has little special 
pathological importance. Another urinary pigment has been described by 
Dr. Thudichum under the name of urochrome. The pink coloring matter, 
however, termed purpurine or uro-erythrine, is a pathological product. 
Its chemical constitution and source have not been ascertained ; but it is 
common in febrile and inflammatory affections and in cases of organic 
disease, especially of the liver, and has a remarkable affinity for uratic 
sediments to which it clings and imparts its special tint. Indican, the 
peculiar body by whose decomposition indigo-blue and indigo-red are 
obtained, has been ascertained by Schunck to be a normal constituent of 
urine. It is to this source that the occasional presence of indigo-blue in 
decomposing and morbid urine appears to be due. 

8. Odorous matters The peculiar smell of normal urine is due to the 

presence of minute proportions of certain volatile organic acids, which 
need not be specified. This smell is well marked when the urine is acid ; 
but when it is alkaline from fixed alkali it acquires a sweetish odor instead, 
and when alkaline from decomposition becomes ammoniacal. Diabetic 
urine has a peculiar sweetish smell. 

9. Grape or starch sugar. Glucose. Dextrose (C 6 H 12 0 6 , H 2 0) — A 
trace of this substance is frequently, if not always, present even in healthy 
urine. Occasionally it is found in excess under the influence of various 
morbid conditions of the system. Its habitual presence in quantity is the 
distinctive feature of the malady known as diabetes mellitus. Diabetic 
urine is usually of high specific gravity, has a sweet taste, very rapidly 
develops torulge, ferments on the addition of yeast with the disengagement 
of carbonic acid gas, and (as one of the names of its saccharine constituent 
implies) rotates the plane of polarization to the right. 

Many tests for the presence of sugar, some founded on the facts above 
enumerated, have been devised. Of these Trommer's or the copper test, 
which depends on the influence f possessed by grape-sugar in decomposing 
the salts of copper and throwing down the insoluble red sub-oxide, is prob- 
ably the best. It may be applied as follows : — 

Mix the suspected urine with half its volume of solution of caustic pot- 
ash or soda. If much precipitate be produced, it should be separated by 
filtration. Then add a drop or two of a dilute solution of sulphate of cop- 
per, and heat the mixture in a test-tube. Even before the boiling point is 
reached (if sugar be present) the characteristic precipitate will begin to 
appear ; and as soon as this point has been attained the heat should be 
withdrawn, since other substances besides sugar effect by prolonged ebul- 
lition a reduction of cupric salts. The effect of this process on diabetic 
urine is that after a few seconds the mixture suddenly turns of an intense 
opaque-yellow color, and in a short time an abundant yellow or red sedi- 
ment falls to the bottom. The test is best applied by using a ready-made 
alkaline solution of tartrate of copper. Moreover, by means of a standard 
solution of this kind the quantity of sugar in urine can also be estimated. 

a. Fehling's solution, which is employed for the above purpose, is thus 
prepared : Dissolve 34-64 grammes of pure crystallized sulphate of copper 
in 200 c. c. of distilled water. Separately dissolve 173 grms. of pure crys- 
tals of Rochelle salt in 480 c. c. of solution of caustic soda (sp. gr. 144). 



726 



DISEASES OF THE GENITO- URI N ARY ORGANS. 



Mix the two solutions and dilute up to a litre. 10 c. c. of the mixture 
contain -3464 grm. of cnpric sulphate or -108 grm. of cupric oxide, and 
represent -05 grm. of pure anhydrous grape-sugar. This mixture has a 
great tendency to spoil by keeping. To obviate this it is advantageous to 
prepare the solutions as follows: Dissolve 34-64 grms. of cupric sulphate 
in distilled water, dilute up to a litre, and keep in a separate bottle. Dis- 
solve 173 grms. of Rochelle salt in 350 c. c. of distilled water, and heat to 
boiling: on cooling add 600 c. c. of solution of caustic soda (sp. gr. 1-12) 
that has been previously boiled, and make up to a litre with distilled water. 
The second solution is to be kept in a separate bottle, and to be mixed 
with the former in equal proportions when required for use. 

To estimate the amount of sugar present in diabetic urine dilute 10 c. c. 
of urine with distilled water up to 200 c. c. ; and pour into a Mohr's burette. 
This dilution is to reduce the sugar below 1 per cent. Then place 10 c. c. 
of Fehling's solution, or 20 c. c. of the mixture last considered, in a small 
flask, add distilled water up to 50 c. c, and boil the whole over a Bunsen's 
flame — the flask resting on some wire gauze immediately below the Mohr's 
burette. Then allow the diluted urine to flow slowly into the boiling cop- 
per solution until the blue color has nearly disappeared. After this point 
the urine must be added more cautiously, and the flask well-agitated after 
each addition. The precipitated sub-oxide settles rapidly on removing 
the flame, thus allowing any tinge of blue in the supernatant fluid to be 
readily seen on holding the flask obliquely over a white ground. So long 
as any trace of color remains more urine must be added, and the boiling 
must be continued. To make sure that all the copper has been precipi- 
tated, a little of the test-mixture should be filtered and tested with ferro- 
cyanide of potassium and acetic acid. The appearance of a brown colora- 
tion or precipitate indicates the presence of copper. When once the 
examination of the urine has been commenced it should be completed as 
soon as possible, to prevent any re-solution of the sub-oxide. Supposing 
60 c. c. of the diluted urine have been required by the 10 c. c. of Fehling's 
solution, then every 60 c. c. of the diluted urine, or every 3 c. c. of the 
urine itself (since it has been diluted twenty times), contains '05 grm. 
of sugar, or about 1*6 per cent. , 

b. Another method, known as K?iapp , s, may be employed. It pos- 
sesses certain advantages over Fehling's processes. The test solution is 
easier to make, it keeps a long time without alteration, the analysis 
requires a shorter time, and the termination of the reaction is more easily 
determined. The process is based on the power possessed by grape-sugar 
of reducing to the metallic state the mercury contained in a boiling alka- 
line solution of mercuric cyanide — 100 parts of sugar reduce 400 parts of 
cyanide. The standard solution is prepared by dissolving 10 grms. of the 
cyanide in 600 c. c. of distilled water, adding 100 c. c. of solution of 
caustic soda (sp. gr. 1-145) and diluting up to a litre with distilled water. 
40 c. c. of the mercuric solution (containing -4 grm. of the cyanide, and 
equivalent to -1 grm. of sugar) are heated in a flask, and the diluted urine, 
as in Fehling's process, slowly added until the whole of the mercury is 
precipitated. The mercury falls rapidly, and the completion of the pro- 
cess can be ascertained by bringing a drop of the supernatant fluid in 
contact with a piece of wet filter paper which has been exposed to the 
fumes of hydrochloric acid, and subsequently to sulphuretted hydrogen. 
A trace of dissolved mercury gives at once a yellow or brownish colora- 
tion. 



I 



URINE IN HEALTH AND DISEASE. 



727 



Both of the above analyses should be repeated a second time in order to 
insure accuracy. 

[Fermentation test. — Add to the suspected urine a small quantity of 
yeast, when, if sugar be present, fermentation will soon be set up. The 
urine, after the process is completed, will be found to have lost in specific 
gravity. The difference will indicate very closely the number of grains 
of sugar in each ounce of urine, from which it will be easy to calculate the 
quantity passed in twenty-four hours. Again, the amount of sugar con- 
tained in the urine may be approximately estimated by collecting and 
measuring the carbonic acid given off during fermentation, since each 
cubic inch of the gas nearly represents a grain of sugar.] 

10. Amorphous phosphate of lime (Ca 3 ,2P0 4 ) — This precipitates only 
in alkaline urine ; it forms an amorphous sediment like that of the urates, 
but does not carry with it the urinary coloring matter. The application 
of heat increases the precipitate, and not unfrequently causes it. It is 
dissolved, however, on the addition of a drop or two of nitric acid. It 
often forms an iridescent pellicle on the surface. 

11. Crystallized phosphate (CaH,P0 4 ) — Dr. Roberts regards this 
sediment, which is rare, as an accompaniment of grave disorders. It 
occurs in rods and needles, which are often arranged in tufts and stars. 

12. Ammoniaco-magnesian phosphate (H 4 NMg,P0 4 ) always falls in 
ammoniacal urine. Its crystals occasionally appear in slightly acid urine ; 
but are much more frequently observed in that which is alkaline, and then 
often associated with the amorphous phosphate. They are occasionally 
met with as an habitual constituent of freshly- voided urine. The ordinary 
crystalline form is that of a triangular prism with bevelled ends. But 
this is liable to numerous modifications. 

13. Oxalate of lime (CaC 2 0 4 , 2H 2 0). — The presence of oxalic acid in 
urine is not surprising considering that it, with carbonic acid, is one of 
those ultimate substances into which organic matters become reduced. Its 
presence is doubtless in the majority of cases due to such reduction, but 
sometimes it depends on the ingestion of articles of diet, such as rhubarb, 
which contain it. It occurs in the urine in combination with lime, usually 
forming small oblique octahedral crystals, and occasionally dumbbell- 
shaped bodies. The crystals generally fall, entangled with the mucus, 
and when large may be seen as shining points with the naked eye. Their 
occasional presence is a matter of little importance; but when they are of 
habitual occurrence there is reason to fear the formation of oxalate of lime 
calculi, and there is often some obvious impairment of health. Oxalate of 
lime rarely occurs in alkaline or neutral urine. It is readily soluble in 
the mineral acids; and precipitable from solution by excess of ammonia. 

14. Carbonate of lime (CaC0 3 ) is sometimes deposited as an amorphous 
powder in alkaline urine, and is occasionally found in the form of minute 
rounded calculi, with a well-marked concentric structure. 

15. Albumen. — This substance is seldom met with in healthy urine, and 
its presence, in any quantity at least, is one of the most significant indica- 
tions of renal disease. It is observed under various circumstances. When- 
ever suppuration occurs in connection with any of the urinary organs, and 
pus is discharged into the urine, albumen is present in small proportion. 
In many specific fevers and other febrile disorders, albuminuria is liable 
to occur. In congestion of the kidneys, due to heart disease, bronchitis, 
or obstruction of the renal veins or arteries, again, albuminuria is fre- 
quently observed. The most important causes of this condition, however, 



728 



DISEASES OF THE GENITO- URINARY ORGANS. 



are inflammation of the kidney, and those various chronic lesions which 
are usually comprehended in the term ' chronic Bright's disease.' It has 
occasionally been discovered in healthy urine shortly after a meal of eggs. 

The presence of albumen in the urine may always be recognized by its 
coagulation under the influence of heat or nitric acid. To apply the 
former test, a portion of the urine should be placed in a test-tube and then 
boiled by means of a spirit-lamp. If it contain albumen, opaque flakes 
form in it, which render it more or less turbid, and gradually fall to the 
bottom of the glass. If there be much albumen present, turbidity appears 
before the urine begins to boil ; if there be only a trace, actual ebullition 
is essential to its production. In the employment of heat one or two pre- 
cautions are necessary to be observed In the first place, albumen is not 
precipitated if the urine be alkaline, and hence such urine should first be 
acidified by the addition of a few drops of acetic acid. In the second 
place, in slightly alkaline or neutral urine, heat is apt to throw down a 
deposit of amorphous phosphates. These, however, dissolve on the addi- 
tion of an acid. The nitric acid test may be employed as follows : A 
test-tube should be filled to a depth of ^ or ^ inch with strong nitric acid, 
and then a small quantity of urine should be slowly poured down the side 
of the inclined tube so that it may rest on the acid without mixing with 
it. If albumen be present, a white cloud soon appears in the layer of 
urine which is in contact with the acid. The fallacies which may arise in 
connection with this test are : first, that the urine of patients who are 
taking cubebs or copaiba is apt to become slightly turbid under the influ- 
ence of nitric acid ; second, that in concentrated urine and such as is rich 
in urea, some deposition of urates or of nitrate of urea may occur; and, 
third, that the addition of a very minute proportion of nitric acid does not 
always precipitate albumen, while the addition of an excessive quantity 
may prevent its precipitation altogether. [If, however, care be taken to 
prevent the intermingling of the two liquids, it will very rarely happen 
that even small quantities of albumen will escape detection, and there will 
generally be no difficulty in distinguishing a precipitate due to its presence 
from one composed of the urates. The former is deposited just where the 
urine and acid come in contact, and has borders above and below as 
sharply defined as if cut with a knife; whereas, on the other hand, the 
latter occupies a position a line or two above this, and while its lower 
border is well defined, it has a tendency to be drawn out in shreds above. 
This test will sometimes show the presence of both of these substances in 
the same urine, in which case there will be two precipitates, each having 
its own peculiar characteristics!] A saturated solution of picric acid also 
precipitates albumen. The relative quantity of albumen present in any 
specimen of urine may be roughly but conveniently estimated by boiling 
the whole of the slightly acidified portion placed in a test-tube, and then 
allowing the coagulated flakes to subside. 

16. Blood may be found in the urine in various proportions and in dif- 
ferent conditions, and may be furnished by any part of the urinary tract, 
from the kidneys downwards. The greater the quantity of blood passed, 
and the nearer its source to the external urethral orifice, the less will it 
deviate from the normal condition of blood, and the more readily will it 
be recognized. Its presence may be due to injury, congestion, inflamma- 
tion, carcinomatous and other like growths, concretions, or parasites, in- 
volving either the substance or pelvis of the kidney, or some other part of 
the excretory apparatus, such as the ureter, bladder, or urethra. Hrema- 



URINE IN HEALTH AND DISEASE. 



729 



turia occasionally also follows the use of cantharicles or other drugs, and 
is frequently met with not only in those febrile disorders (smallpox, scarlet 
fever, and the like) which are attended with albuminuria, but in purpura, 
scurvy, and other affections which assume a petechial character. When 
much blood is effused, it occasionally coagulates in the bladder ; and may 
even coagulate more or less imperfectly in the chamber-pot. When pres- 
ent in smaller quantities and diffused uniformly throughout the urine, it 
imparts to it a slight degree of opacity or turbidity, and a tint resembling 
that of a dilute solution of the compound infusion of roses, or a peculiar 
smoky or dirty reddish-brown hue varying in depth and distinctness accord- 
ing to the quantity of blood present. Sometimes the urine resembles 
porter. On standing, it usually deposits a grumous or coffee-ground-like 
sediment. The presence of blood is additionally proved by the detection 
of albumen in the urine by the usual tests, and by submitting a specimen 
to microscopic examination, when almost always blood-corpuscles will be 
readily detected, sometimes disk-like, sometimes globular, sometimes cre- 
nate, occasionally retaining their coloring matter, but usually colorless, 
having imparted their pigment to the fluid in which they float. In a pe- 
culiar affection, shortly to be described — paroxysmal hematuria — although 
the urine contains abundance of blood, distinct blood-corpuscles are rarely 
detected. And occasionally (as Dr. Mahomed has shown to be especially 
the case at a certain period in scarlet fever, prior to the occurrence of 
albuminuria and anasarca), the coloring matter of the blood alone trans- 
udes into the urine, where it may be detected either by the spectroscope 
or by the guaiacum test. The latter may be applied as follows : Place a 
drop or two of the urine in a small test-tube, add one drop of tincture of 
guaiacum and a few drops of ozonized ether ; agitate, and then allow the 
ether to collect at the top. If blood pigment be present, the ether acquires 
a blue color, leaving the urine below colorless. No saliva must be mingled 
with the urine, and the patient must not be taking any salt of iodine. 1 
Further, unless the tincture be freshly prepared, the reaction is liable to 
fail. 

17. Bile. — The coloring matter of the bile and the biliary acids are 
found in greater or less abundance in the urine in cases of jaundice. The 
former may, according to its amount, impart merely a yellowish tint, 
scarcely or not at all distinguishable from that of normal urine, or any 
variety of shade between this and a deep olive-green. Bile-stained urine 
seen by reflected light often looks almost black. The presence of biliary 
pigment in the urine may be readily detected by the addition of strong 
nitric acid, which produces, where the fluids first come into contact, an 
evanescent succession of green, blue, violet, and red tints. The test may 
be applied, either by placing a few drops of urine and a few drops of nitric 
acid close to one another on a white porcelain surface, and then allowing 
them to come together ; or by putting a little nitric acid at the bottom of 
a test-tube, and pouring a small quantity of urine carefully on the top of 
it without allowing them to mix. In the former case the play of colors 
takes place at the line of mixture, in the latter in the horizontal plane of 
contact. Dr. G. Harley considers that the presence of the biliary acids in 
the urine is characteristic of jaundice from retention of bile. For their 
detection the following process (a modification of Petenkofer's) may be 
employed : Add a few drops of syrup to the urine, and then shake briskly 

1 Mahomed, Med.-Cliir. Trans., vol. lvii. 



730 



DISEASES OF THE G ENITO - URIN AR Y ORGANS. 



in a test-tube until a froth has formed. Next, allow a drop of strong sul- 
phuric acid to flow down the side of the tube. As soon as the acid reaches 
the froth a beautiful purple color develops rapidly. The reaction is facili- 
tated by gently warming the side of the test-tube. 

18. Casts — In almost all cases in which albuminuria or hematuria is 
due to morbid conditions of the secreting structure of the kidneys, and 
occasionally in specimens of urine which seem to be free from both blood 
and albumen, microscopic cylinders which have been moulded in the uri- 
nary tubules, and are therefore termed casts, may be detected with the aid 
of the microscope. Of these several varieties may be distinguished. The 
following enumeration comprises the more common of them. a. Epithe- 
lial casts consist of renal epithelium. Occasionally the epithelium differs 
little from the normal epithelium of the tubules. More commonly, the 
cells are granular and degenerating or studded with oil-globules. In other 
cases, the casts are formed mainly, if not entirely, of new-formed cells, 
which then assume an embryonic character, and have, therefore, more or 
less resemblance to pus-cells, b. Hyaline casts. These present two well- 
marked varieties, of which one may be termed mucous, the other waxy. 
The former are exceedingly translucent and delicate, and consequently 
may readily escape detection. They are colorless, homogeneous, or ground- 
glass-like, with little or no refractive power, soft and flexible. They pre- 
sent soft but definite edges, are generally narrow and often of considerable 
length. They are proteinous, but not fibrinous ; and are unaffected by 
acetic acid. The waxy casts also are transparent and homogeneous ; but 
they are highly refractive, and therefore present well-marked shaded edges. 
Moreover, they are brittle, are apt to present transverse fractures, and vary 
largely in diameter and length. Like the former, they are not acted on 
by acetic acid ; but they readily absorb biliary, blood, or other coloring 
matters, c. Granular casts. These vary in size, but are often of con- 
siderable bulk, and are studded more or less thickly, and more or less 
irregularly with granular matter, which often renders them perfectly 
opaque. They are hyaline, generally waxy, casts which have either under- 
gone granular degeneration in a greater or less degree, or are studded with 
or enveloped in the debris of degenerating cells. Indeed, compound granule- 
cells are often seen distinctly imbedded in them. d. Fatty casts are char- 
acterized by the presence of obvious fat-globules, which are sometimes of 
considerable size. Such globules may be observed in either epithelial, 
hyaline, or granular casts. The fatty matter is not pure olein, but seems 
generally to be a mixture of this with cholesterine and some albuminous 
matter, e. Blood casts. Generally, in renal hematuria the casts consist, 
in a greater or less degree, of coagulated fibrine entangling the corpuscular 
elements of the blood. The basis of the casts is here purely fibrinous ; it is 
fibrillated, and dissolves in acetic acid. The blood-corpuscles may present 
nearly their normal characters ; they are generally, however, compressed 
and angular, and are often broken down and individually undistinguishable. 
The casts are necessarily more or less deeply pigmented. Blood-corpuscles 
or blood-pigment may be present, in greater or less proportion, in epithelial 
or hyaline casts. 

It occasionally happens that the various casts above described, and more 
especially perhaps the w r axy and granular casts, contain crystals of either 
uric acid, oxalate of lime, or triple phosphate, or granules of urate of soda, 
or refractive globules looking like oil, but consisting of the crystalline 
bodies just named in combination with animal matter. 



URINE IN HEALTH AND DISEASE. 



731 



As regards the sources of urinary casts, it is important to bear in mind 
that the convoluted tubes of the kidneys which are functionally the most 
important can scarcely yield them, inasmuch as they are of comparatively 
large diameter, and are separated from the straight or collecting tubes by 
the narrow loops of Henle. Indeed there is little doubt that casts found 
in the urine come exclusively from the loops of Henle and the straight 
I tubes, that the descending limbs of the loops furnish the smallest, the 
j ascending limbs those of intermediate size, and the straight tubes, and 
I more especially their terminal portions, the largest casts. 

On these and other grounds the significance of casts is less than is 
! generally supposed. They are often absent in cases of albuminuria or 
. • chronic Bright's disease ; and mucous casts are occasionally observed in 
j jaundice, and in cases in which there is neither albuminuria nor kidney 
disease, and even in health. Epithelial casts usually imply acute affec- 
tions ; large hyaline, fatty and granular casts, chronic and degenerative 
disease ; while mucous casts have no special significance. 

19. Mucus and pus In normal urine but little mucus is present; it 

falls as a scarcely perceptible cloud, and contains perhaps traces of vesical 
and urethral epithelium, and in the female squamous vaginal epithelium. 
When, however, there is any inflammatory condition of the mucous lining 
of the urinary channels or reservoirs, the mucous secretion becomes in- 
creased, cells are discharged in excess, and immature forms, in other 

j words, cells identical with those of pus, are produced in greater or less 
abundance. The transition between mucus and pus is almost imperceptible. 
The discharge, if sufficiently abundant, renders the urine turbid and 
I slightly albuminous ; and a sediment, which may present a greenish-yellow 
I hue, presently forms. If the urine retain its acid reaction, this sediment 
is readily miscible with the urine ; if, however, it become, as it is very 
apt to become, alkaline, then the sediment becomes tenacious and ropy. 
The secretion of inflammatory mucus has a remarkable influence in pro-? 
moting the decomposition of urea ; the urine, therefore, in these cases has 
a great tendency to become ammoniacal, to deposit earthy phosphates, and 
to acquire irritant properties. The abnormal secretions here described are 
most commonly furnished by the inflamed mucous membrane of the pelvis 
of the kidney, or bladder. But it must not be forgotten that pus may be 
poured into the urinary passages, either from renal abscesses or in conse- 
quence of the rupture of some neighboring abscess into them, and that 
cells identical with pus-cells may escape from the renal tubules. Pus can 
be readily recognized by its microscopic characters. [Its presence may 
also be readily recognized by the following test : Thoroughly agitate in a 
test-tube a drachm of urine with about the same quantity of liquor potassas, 
when, if pus is present, the liquid will become ropy and viscid.] 

20. Fat, excepting in connection with renal casts, is of rare occurrence 
in the urine. The presence of fluid fat in the form of globules is said to 
have occasionally been observed. Crystals of cholesterine also have been 
met with. In a case of Dr. Murchison's, the cholesterine was traced to a 
pyonephritic cyst. The most interesting cases of fatty urine, however, 
are those in which this fluid presents a milky or chylous character, due to 
the presence of fatty matter in a molecular or amorphous condition. In 
these cases the urine contains albumen, fibrine, and leucocytes, in addition 
to fat; it hence tends to coagulate spontaneously; it coagulates with heat; 
a creamy layer rises to the top when it is allowed to stand ; and it may be 
rendered clear, and the fat be separated, by agitating it with ether. 



732 DISEASES OF THE GENITO-URIN ARY ORGANS. 



Many of the globules which are commonly regarded as fat, and look 
like it, are really composed of some of the crystalline constituents of the 
urine in combination with animal matter, as may be shown by the effects 
of reagents and the appearance of a cross when examined with polarized 
light. 

21. Morbid growths Tubercle, carcinoma, and other growths are apt 

to arise in various parts of the urinary organs : and it might hence be sup- 
posed that their characteristic elements should be occasionally discovered 
in the urine. It must be exceedingly rare, however, for such specific in- 
dications to be met with in connection with disease of the kidneys. In 
villous growths of the bladder, fragments may, no doubt, be detached and 
occasionally discovered in the urine. It must be borne in mind, however, 
that the cells of the vesical epithelium have a great resemblance to typical 
cancer cells, and may be easily mistaken for them. 

22. Spermatozoa are sometimes present in the urine, and may be readily 
recognized in the sediment. Their presence is of little clinical importance, 
unless other symptoms combine to indicate the existence of abnormal 
spermatorrhoea. 

23. Animal and vegetable organisms Hydatids are occasionally de- 
veloped in the urinary organs, or hydatid cysts may open into them. The 
urine under such circumstances may present actual hydatids or echinococci, 
or fragments of one or the other. The peculiar laminated character of the 
hydatid membrane, and the hooklets of echinococci, are, under the micro- 
scope, quite unmistakable objects. In the endemic hematuria of Egypt, 
the Cape, Natal, and other parts of Africa, the symptoms are due to the 
presence, in the veins of the pelvis of the kidney, ureter, and bladder, of a 
small unisexual parasite, termed the bilharzia haematobia. The presence 
of this affection may be recognized by the discovery in the urine of the ova 
and free embryos of the parasite. The filaria sanguinis hominis is found 
in some cases of chyluria. 

Sarcinas have been observed in the urine when passed from the bladder. 
Lastly, bacteria and penicillium form rapidly in urine undergoing decom- 
position, and the yeast-plant in that of diabetic patients. 

B. Concretions. 

These may occur in the form of a fine sand, in which case they are 
termed gravel, or in masses varying from the size of a tare or mustard seed 
upwards, when they are known as calculi; and may consist of any of the 
solid matters which have been described as occasionally separating from 
the urine, either separately or in combination. The most important of 
them are the uric acid, the uratic, the cystine, the xanthine, the oxalate 
of lime, the phosphatic, and the carbonatic. 

Urinary concretions always contain more or less organic matter com- 
bined with their main ingredients, and in a large number of cases the 
nucleus has a different chemical constitution from the layers subsequently 
formed. Further, any foreign body, whencesoever derived, may form the 
nucleus around which urinary deposits accrete. 

1. Uric acid concretions are the most common. They constitute five- 
sixths of the total number of renal calculi, and wholly or in part the great 
majority of those found in the bladder. Uric acid gravel consists of angu- 
lar groups of crystals. Renal calculi of this material are small, round, or 
oblate-spheroidal, often tuberculated bodies, which vary in color from pale 



URINARY CONCRETIONS. 



733 



fawn to deep reddish-brown. In the bladder they attain a large size. 
They are hard, have a specific gravity of about 1-5, and are formed in con- 
centric laminae. 

2. Uratic calculi are rare, and occur mostly in children under puberty. 
They are small, slate- or clay-colored on the surface, smooth or granular, 
formed in thin ill-marked laminae, and very friable. They are readily 
soluble in boiling water. 

3. Cystine calculi are very uncommon. When pure they are yellow, 
transparent, wax-like, and soft ; the outer surface is somewhat crystalline, 
the sectional surface radiated. After long exposure to daylight they tend 
to assume a pale green color. The circumstances which determine their 
formation are not known, but the tendency to them seems to run in families. 

4. Xanthine calculi are also exceedingly rare, and have a close resem- 
blance to those of uric acid. 

5. Oxalate of lime calculi are next in frequency to those of uric acid. 
When in the kidney they are generally small, smooth, and of a dark color. 
Here, however, but more particularly in the bladder, they often attain a 
large size, and are then usually tuberculated or spiny on the surface, con- 
stituting what are called mulberry calculi. These are laminated — the 
successive laminae presenting a wavy or crenated character. Oxalate of 
lime calculi are exceedingly hard, and, though generally dark, vary much 
in color. When very pure they are occasionally milk-white. 

6. Calculi of amorphous phosphate of lime, or bone-earth, and of am- 
moniac o-magnesi an phosphate, are both exceedingly rare. The fusible 
calculus, which is composed of a mixture of these salts, on the other hand 
is very common. This precipitate commonly takes place in ammoniacal 
urine, and hence is met with in the renal pelvis or the bladder affected 
with chronic inflammation ; and hence, further, it is specially apt to occur 
when calculi of other composition are producing irritation. Phosphatic 
matter, indeed, rarely forms the nucleus of a calculus ; but it tends to ac- 
cumulate on the surface of other calculi ; and, when once it begins to col-" 
lect there, is rarely succeeded by any other form of deposit. Phosphatic 
calculi are light, loose-textured, imperfectly laminated or amorphous, and 
white, gray, or dark -yellow. 

7. Carbonate of lime very seldom forms urinary calculi in the human 
being. It takes part, however, in the formation of the minute, dark- 
colored, laminated concretions (sometimes called corpora amylacea) which 
are met with in the prostate. Dr. Roberts quotes a case of Dr. Hal- 
dane's in which it was proved by post-mortem examination that carbonate 
of lime calculi, presenting similar characters, may be formed in the pelvis 
of the kidney and passed with the urine. 

Calculi formed of blood, albumen, or fat, have occasionally been met 
with, and Dr. Ord has recently discovered one consisting of nearly pure 
indigo. 

C. The Specific Consequences of the Retention of Urea and other effete 
matters in the Blood. 

Structural disease of the kidneys, involving both organs generally, is 
attended with one important consequence : — namely, the prevention, in a 
greater or less degree, of the elimination of urea, uric acid, and other pro- 
ducts of the retrograde metamorphosis of nitrogenous matters, and their 
consequent retention in the blood and in the fluids which bathe the tissues. 



734 



DISEASES OF THE GENTTO - URINARY ORGANS. 



Following upon this retention, and in part dependent on it, but in part, no 
doubt, dependent on the constant loss of albumen which commonly attends 
diseases of the kidneys, the blood undergoes deterioration ; it grows watery, 
poor in albumen and corpuscles, and at the same time fibrine becomes rela- 
tively increased ; the patient gets anaemic and suffers from many of the 
usual consequences of anaemia. But, in addition to these phenomena, 
others of great gravity, and in the aggregate special to renal disease, sooner 
or later supervene. These have been attributed simply to the retention 
of urea, but the experimental introduction of urea into the blood seems to 
show that this substance has little or no poisonous property. It can 
scarcely be denied, however, that the phenomena in question are really 
referable to the retention, either of urea or of some of the less oxidized 
matters which accompany it, namely, uric acid, kreatine, kreatinine, and 
the like. Frerichs maintains that some of them are due to the conversion 
of urea in the blood into carbonate of ammonia. The chief morbid phe- 
nomena here referred to are — thickening and contraction of the smaller 
bloodvessels ; hypertrophy of the heart ; anasarca and other dropsical 
effusions ; local congestions and hemorrhages ; inflammation of different 
organs, mainly those of the thorax ; and, lastly, various functional diseases 
of the digestive and other organs, but, above all, of the central nervous 
system. 

1. Thickening and contraction o f the smaller bloodvessels. — Dr. G. John- 
son showed some years since that in cases of chronic renal disease the 
walls of the minute arteries, both in the kidneys themselves and generally 
throughout the system, became extremely thick, and at the same time 
much contracted. He attributed the thickening to hypertrophy of the 
muscular coat and the narrowing to the tonic contraction of this coat, and 
regarded the combined phenomena as an effort of nature to oppose the 
transmission of poisoned blood to the tissues. The thickening of the 
arterial tunics and the contraction of the arterial channels in chronic renal 
disease are now established facts. It has, however, lately been maintained, 
more particularly by Sir W. Gull and Dr. Sutton, that the thickening is 
the result not of muscular hypertrophy, but of a ' hyaline-fibroid' conver- 
sion ; that it is in fact a change not unlike that which occurs in cirrhosis 
of the liver and sclerosis or other organs — a change which in a sense may 
be regarded as degenerative. In these latter views, so far as we have 
stated them, we are disposed to concur. 

2. Hypertrophy of the heart, independent of valvular affection, has long 
been recognized as one of the most obvious attendants on chronic kidney 
disease. The hypertrophy is general, and associated with more or less 
dilatation ; but the changes are, perhaps, more obvious in the left ventricle 
than elsewhere. Dr. Quain has shown that the thickening of the walls is 
due in some degree to increase of the connective tissue, in other words to 
a kind of sclerosis; there is no doubt, however, that it is mainly dependent 
on muscular overgrowth, and that the stimulus to this overgrowth consists 
in some obstacle which the heart's action has to overcome. But since the 
valves and larger arteries are all, for the most part, healthy, this obstacle 
is not presented by them. There are obvious reasons why the veins must 
be considered to be inoperative in the matter. We are compelled, there- 
fore, to look to the small arteries and capillaries. And that the obstruc- 
tion really does reside in these vessels is clearly shown by the high tension 
which by sphygmographic observation has been proved to prevail through- 
out the arterial system in such cases. It was formerly believed that the 



CONSEQUENCES OF THE RETENTION OF UREA. 



735 



obstruction was caused by some abnormal attraction between the capillary 
bloodvessels or the tissues outside them and the morbid blood. It is, 
however, doubtless due to the contraction of the channels of the capillary 
arteries. Dr. Sibson has shown that generally in these cases the contrac- 
tions of the two sides of the heart are not quite synchronous, and that there 
is a tendency, therefore, to reduplication of the heart's sounds. 

3. Anasarca and other dropsical effusions. — Kidney disease is one of 
the most frequent causes of general anasarca. This condition often reveals 
itself first in regions in which the connective tissue is lax, as the scrotum, 
eyelids, and conjunctiva?, and is often recognized in the face before it 
appears in the lower extremities. There is generally neither lividity nor 
dilatation of veins ; but the swollen surface presents an anaemic, wax-like 
character. Its cause is somewhat obscure. It is evidently not passive, 
for there is neither venous obstruction nor venous hyperemia ; nor again 
is there any obvious impediment to the healthy action of the lymphatic 
vessels. It must then be due either to some peculiar tendency in the 
serum of the blood to transude through the capillary vessels, or to the 
sweating of this fluid through the walls of the smaller arteries in conse- 
quence of the heightened pressure which the blood within them exerts. 
In reference to this question it should be mentioned that Dr. Mahomed 
has recently shown that in scarlet fever there is a stage, preceding the 
occurrence of anasarca, and even the appearance of blood or albumen in 
the urine, during which high arterial tension prevails as demonstrated by 
the resistance of the pulse to pressure and the form of the pulse-trace, and 
during which also the coloring matter of the blood may sometimes be re- 
cognized in the urine. The anasarca is not merely subcutaneous, but may 
involve the tissues of the larynx, the pulmonary texture, and other parts 
of the system ; and is commonly associated with effusion into the several 
serous cavities. It is usually attended with a dry skin and considerable 
diminution of urine ; to which circumstances and to coexistent anaemia 
the presence of dropsy is no doubt in part attributable. 

4. Congestions and hemorrhages are among the consequences of kidney 
disease. The most important of them are : effusion into the substance of 
the brain, causing apoplectic symptoms ; effusion into the choroid and re- 
tinal coats of the eye (albuminuria retinitis), attended with aching across 
the temples and at the occiput, and leading to atrophic changes and more 
or less impairment of vision, or even absolute blindness ; and effusion into 
the lung-substance, producing the condition known as pulmonary apoplexy. 
The causes of these hemorrhages are, in part, the same as induce anasarca; 
but in chronic renal disease there is a marked tendency to atheromatous 
and fibroid degeneration of arteries, and hence effusions of blood are in 
some cases due to rupture of diseased and enfeebled vessels. 

5. Inflammatory affections are of frequent occurrence. The most com- 
mon and serious of these are inflammations of the pericardium and pleurae, 
of the larynx, bronchial tubes, and lungs. But inflammation may also 
affect the abdominal viscera ; and, indeed, no part is wholly exempt from 
liability to it. When anasarca is present it is of course common for an 
erythematous blush to make its appearance somewhere or other on the 
surface, and even for erysipelas or superficial gangrene to occur. 

6. The junctional consequences of renal disease are very numerous. 
Dyspepsia, nausea, vomiting, and diarrhoea, the former three especially, 
are common phenomena, even when the stomach is healthy. Palpitation 
and dyspnoea, or hurried respiration, are not unfrequently observed in cases 



736 



DISEASES OF THE GE NITO - URINARY ORGANS. 



in which the heart and lungs present little if any sign of disease. Drowsi- 
ness, headache, irritability, hypochondriasis, and even more or less 
maniacal disturbance and wakefulness, are all of them liable to arise. 
But the most serious of the functional disturbances of the nervous system 
are coma and convulsions. These are generally preceded by some of the 
less grave mental phenomena above enumerated. The convulsions occur 
in paroxysms which almost exactly simulate those of true epilepsy, and, 
associated with coma, often succeed one another at short intervals until 
they terminate in death. Coma or apoplectic symptoms may occur inde- 
pendently of convulsions. 

D. The non-specific Morbid Phenomena which attend on and characterize 
Lesions of ths Kidneys. 

Other symptoms which attend and indicate the presence of renal disease 
are totally independent of impairment or suppression of the proper func- 
tions of the kidney. These are symptoms which are determined by the 
locality of the diseased organ, and such as are referable to it as a focus of 
inflammation or other morbid processes. Among the former may be com- 
prised pain and tenderness, tumor, and the effects of pressure ; amongst 
the latter the general symptoms of inflammatory fever when the organ is 
inflamed, the cachexia which attends the development of malignant dis- 
ease, and the anosmia which results from the continued escape of blood, or 
of that important element of the blood — albumen. 



II. PYELITIS. 

Causation Inflammation of the lining membrane of the kidney may 

be excited in various ways. It seldom results from exposure to cold, or 
arises in association with ordinary nephritis. It may, however, be induced 
by the use of certain medicinal irritants, such as cantharides and turpen- 
tine, which probably induce at the same time a similar condition in the 
lining membrane of the bladder, and in the secreting tissues of the kidney. 
But its most frequent cause is direct irritation of the mucous surface, due 
either to the constant fretting of a renal calculus or to the influence of un- 
healthy discharges or decomposing urine, as occurs in cases of long-con- 
tinued obstruction of the urinary passages. Independently of the last 
condition, vesical inflammation is- apt to creep by continuity along the 
ureter to the pelvis, and thence to the infundibula and calyces. 

Morbid anatomy The anatomical signs of pyelitis are congestion, 

thickening and softening of the mucous membrane, sometimes associated 
with interstitial hemorrhage ; and the discharge from its surface of mucus 
containing shed epithelial cells and pus-like corpuscles, and, it may be, 
blood. If the affection be persistent or intense, other phenomena proba- 
bly supervene ; the thickened mucous membrane may become opaque, 
yellow, or gray, and lose its vivid redness ; suppuration may arise ; false 
membranes may be formed ; or ulceration may take place. Further, the 
effect of the unhealthy products of the mucous surface upon the urine is 
to render it ammoniacal and to promote the precipitation of earthy phos- 
phates, which are then apt to concrete in more or less abundance on the 



PYELITIS. 



737 



inflamed surface. Other changes which are liable to ensue in the course 
of pyelitis depend on impediment to the escape of urine from the inflamed 
cavity ; they are dilatation of the pelvis, infundibula, and calyces, and 
atrophy of the secreting structure. Again, inflammation may extend by 
continuity from the pelvis to the renal substance, and abscesses may con- 
sequently form in it. Suppurative pyelitis, especially if it be confined to 
one kidney, and pus can escape freely from it by the natural passages, 
may continue for years with little or no additional mischief; and even if 
complete obstruction of the ureter arise, it is possible that the whole thing 
may become quiescent, the expanded, atrophied, and indurated renal sub- 
stance losing all its functional power, and the pus in the dilated calyces 
and the rest of the renal cavity drying up into a creamy, putty-like, or 
mortary substance. In other cases, however (and this may happen 
whether the ureter be wholly or only in part obstructed), the renal abscess 
takes another course. It behayes, in fact, as any other abscess originating 
in the vicinity might behave. It first transgresses its original renal limits, 
and then forms sinuses which enlarge and burrow in various directions. 
Thus, they may perforate the diaphragm, and open into the pleura or lung; 
or they may discharge in the loin ; or they may rupture into the perito- 
neum, or open directly into the adjoining colon ; or, descending along the 
psoas muscle, they may point under Poupart's ligament, or gravitate to- 
wards the lesser trochanter ; or lastly, passing into the pelvis, they may 
communicate there with the rectum, bladder, or vagina. 

Symptoms and progress — The specific symptoms of pyelitis comprise 
pain and tenderness in the loin, irritability of the bladder, and modifica- 
tion of the quality of the urine. The pain in the loin is apt to shoot into 
the abdomen, and especially downwards to the labium or testis of the cor- 
responding side and along the inner aspect of the thigh. The tenderness 
reveals itself, and the pain is aggravated, during movement of the body ; 
but especially if the affected side of the abdomen be firmly grasped, or the 
thigh be flexed by its own muscular efforts on the abdomen, in which case 
the enlarging bulk of the psoas muscle presses on the inflamed organ. 
There is probably irritability of the bladder, with pain and scalding in 
micturition. The water is more or less turbid from the presence of mucus, 
or it contains pus or blood or both. It is usually acid ; but, after a time, 
is apt to become ammoniacal from the decomposition of urea, and then to 
deposit amorphous and crystalline phosphates. It does not necessarily 
contain renal casts. Their presence indicates of course simultaneous in- 
volvement of the secreting structure of the kidney. Sometimes the dis- 
charge of pus is profuse ; and both in this and in other cases the products 
of the inflamed surface are not unfrequently passed intermittently — tem- 
porary obstructions probably taking place in the ureter, in consequence of 
which they are retained and accumulate in the renal cavity with aggrava- 
tion of local symptoms, and the urine becomes for the time comparatively 
clear and healthy. The general symptoms are mainly those of inflam- 
matory fever. This assumes for the most part a remittent character, 
and is often attended with rigors. Vomiting and diarrhoea are not unfre- 
quent. 

The symptoms, progress, and results of pyelitis differ in different cases. 
If one kidney only be affected the disease may continue indefinitely with- 
out any very serious impairment of the patient's health — indeed, the organ 
may become totally disorganized with little or no obvious detriment to 
health ; but on the other hand the formation of an abscess is in any case 
47 



738 



DISEASES OF THE GENITO- URINARY ORGANS. 



attended with many risks, and its continuance may cause death either by 
slow exhaustion, aggravated probably by the presence of hectic fever, or 
lardaceous degeneration, or by the supervention of some intercurrent affec- 
tion. When, however, both kidneys are involved, as may be the case in 
calculous pyelitis, and as nearly always takes place when pyelitis is second- 
ary to bladder disease, the symptoms which the patient presents are neces- 
sarily greatly aggravated, and the probability of an early fatal issue is 
much increased. For in addition to the risks which attend disease con- 
fined to one kidney, we have now the additional risks which arise from the 
liability to more or less complete retention of urea in the blood, and those 
which flow from the comparatively wide extent of the inflamed district. 
The patient passes into a typhoid condition, attended with muttering 
delirium, and not unfrequently complicated with epileptiform convulsions 
and coma. 

Accumulation of pus in the kidney may be suspected when the discharge 
of pus with the urine ceases suddenly and continues in abeyance ; it may 
also be suspected when, following upon symptoms indicative of pyelitis, 
rigors take place and at the same time throbbing pain and tenderness 
manifest themselves in the region of one of the kidneys. The diagnosis 
of an abscess must be based partly on the persistence of the above condi- 
tions, partly on the presence of increasing fulness in the neighborhood 
referred to. If the abscess point externally all doubt will be speedily re- 
moved. Under other circumstances many difficulties will necessarily 
present themselves. 

Treatment In the treatment of pyelitis, it is of primary importance 

to ascertain its cause and to remove or obviate it, if possible. Thus, 
when it depends on retention of urine, from stricture, enlarged prostate, 
or paralysis of the bladder, our aim must be (if not to cure these lesions) 
at all events to empty the bladder periodically, and, if necessary, to wash 
it out with antiseptic solutions ; when it depends on the presence of renal 
or vesical calculi, we must endeavor to remove them, or, failing this, to 
maintain rest; if the inflammation be connected with gout, scrofula, or 
any other special cachexia, it will probably be well to modify our treat- 
ment accordingly. 

When pyelitis is acute, and the local symptoms are severe, it may be 
necessary to remove blood from the loin either by cupping or by leeches, 
and to use hot fomentations, poultices, ice-bags, or equivalent applications. 
Counter-irritants, too, always excepting cantharides, may be employed. 
The administration of opium in doses sufficiently large and sufficiently 
often repeated to relieve pain and procure ease and rest, is of essential 
importance. Moderate purging, voluminous bland clysters, and hot baths 
are also valuable aids. When the disease assumes a more chronic char- 
acter, local measures become less important, and opiates also are compara- 
tively little needed. It may, however, still be desirable to give the latter 
in small doses, or to administer some other form of sedative or anodyne, 
such as hyoscyamus, belladonna, or chloral hydrate. But tonics and nutri- 
tious diet now become our most valuable remedial agents ; among the 
former, quinine and the other vegetable bitters, and iron — particularly the 
perchloride — and cod-liver oil, must be especially enumerated. If the 
urine be alkaline, nitro-muriatic acid or some other mineral acid may be 
beneficially combined with the other remedies. Buchu, pareira brava, 
and uva ursi, so much appreciated by surgeons in the treatment of chronic 
inflammation of the urinary bladder, are probably equally useful in the 



CIRCUMSCRIBED AND SUPPURATIVE NEPHRITIS. 



739 



treatment of pyelitis. If the stomach be irritable, as it not ^infrequently 
is, our treatment must be modified with the object of overcoming this irri- 
tability. When there is clear indication of the formation of an abscess 
in or around the kidney, an early and free opening should be made into it, 
for by that means not only may the extension of the abscess in other di- 
rections be prevented, but the cure of the disease will not improbably be 
effected. 



III. CIRCUMSCRIBED AND SUPPURATIVE NEPHRITIS. 

Causation The chief causes of the conditions about to be considered 

are : obstruction of the renal arteries or arterioles by thrombi or (in the 
case of cardiac disease or pyaemia) by emboli ; extension of inflammation 
from the pelvis of the kidney or other neighboring parts ; and accidental 
injury. 

Morbid anatomy The results of arterial thrombi or emboli are the 

same in the kidney as elsewhere. If the obstructed vessel be of large or 
medium size, the district to which it leads becomes deeply congested, blood 
accumulates and stagnates in the arteries, veins, and capillaries, and es- 
capes from them, by rupture or otherwise, not only into the intertubular 
tissues, but into the Malpighian capsules and convoluted tubules. The 
affected district is at first of a deep red or reddish-black color and well 
defined, resembling a patch of pulmonary apoplexy ; but gradually it be- 
comes decolorized and acquires a more or less opaque, buff-colored, cheesy 
aspect, when, if it be examined microscopically, the small vessels will be 
found loaded with pigment-granules and oil, and the epithelium of the tu- 
bules fatty and disintegrating. Sometimes it softens, sometimes suppurates. 
But the disintegrated tissues may also undergo absorption, and a patch of 
cicatricial tissue result. In the embolism of cardiac disease, and especially 
in that occurring in pyaemia, the infarctions are, for the most part, small 
and numerous, and speedily suppurate. In such cases, on removing the cap- 
sule, beads of pus each surrounded by a congested halo may be seen pro- 
jecting from the surface of the organ ; and on making a vertical section, small 
abscesses, or groups of abscesses, similarly surrounded, may be observed 
extending in a radial direction from the periphery to the mucous surface. 
These may vary from mere points up to the size of a filbert or walnut. 
They originate in the intertubular spaces, but soon involve and destroy the 
tubules themselves and the other renal structures. When inflammation 
extends from the pelvis of the kidney, there is often general congestion 
with enlargement of the organ ; but the special feature of such extension 
is the formation, in both medulla and cortex, of minute close-set abscesses 
grouped in comparatively large and well-defined, but not very numerous, 
clusters. Abscesses of the substance of the kidney are attended with vari- 
ous results. Sometimes their contents gradually concrete into a material 
like thick cream or moist plaster of Paris, consisting of disintegrated and 
fatty cells, molecular matter (partly earthy, partly oily), and cholesterine. 
In the most extreme examples of this kind of change, the glandular 
substance of the kidney is hollowed out into a series of cavities, each one 
corresponding to a medullary cone, and its associated cortical lobule, 
which are bounded externally, and separated from one another and from 
the pelvis, by thin fibrous laminae or dissepiments. Sometimes, the ab- 



740 



DISEASES OF THE GENITO-URIN ART ORGANS. 



scesses open and discharge their contents into the infundibula; sometimes 
they extend beyond the limits of the kidney; and then, in either case, 
become indistinguishable, pathologically and clinically, from suppurative 
pyelitis. 

Symptoms. — It would be almost impossible to lay down any definite 
rules for our guidance in reference to the diagnosis of the above affections. 
In a large number of cases the renal symptoms are necessarily more or less 
completely masked by the graver morbid conditions with which they are 
associated. Thus when renal abscesses result from embolism, pyaemia, or 
inflammation commencing in the pelvis of the kidney, the febrile or typhoid 
symptoms referable to the primary malady may perhaps become in some 
degree aggravated, the prospects of amelioration somewhat diminished, the 
fatal event hurried ; but probably nothing points specially to implication 
of the substance of the kidney. Even if the urine be scanty or contain 
blood, albumen, casts, pus-cells, or leucocytes, there is nothing to show 
that such conditions may not be the result of some other variety of renal 
inflammation. If large abscesses form, the symptoms and consequences 
will be those of suppurative pyelitis. 

The treatment of these cases (if they call for treatment) does not differ 
from that of pyelitis. 



IV. ACUTE BRIGHT'S DISEASE. 

(Acute Albuminous, Desquamative, or Tubal Nephritis.) 

Causation. — This affection may be produced by many different causes. 
It may result from simple extension from the inflamed pelvis in pyelitis ; 
it may be due to the influence of cantharides and other poisonous sub- 
stances ; and it frequently accompanies erysipelas, pneumonia, and such 
like grave inflammations, as also variola, measles, cholera, and other spe- 
cific fevers. Its most important causes, however, are exposure to cold or 
wet, and the scarlatinal poison. It occurs also in pregnancy. 

Morbid anatomy In acute Bright's disease the morbid process impli- 
cates in a greater or less degree all the renal textures and for the most 
part is generally diffused and involves both kidneys equally, (a.) The 
vessels — and more especially those of the medulla, the Malpighian tufts, 
and the stellate veins on the surface — become more or less deeply con- 
gested ; and occasionally, undergoing rupture, blood escapes from them 
into the intestinal tissue, or into the Malpighian bodies and tubules. 
{b.) Proliferation of the nuclei in the membrane which invests the Mal- 
pighian vessels, and of those belonging to the muscular walls of the arte- 
rioles, not unfrequently occurs. Lymphoid or embryonic cells sooner or 
later accumulate around the arteries and in the intertubular tissue. They 
are first seen as a rule along the larger branches ; and then accumulate 
about the bases of the pyramids whence they spread partly into the medulla, 
but mainly into the cortex along the interlobular vessels. The process 
may thus reach the surface of the kidney, and by lateral extension impli- 
cate the connective tissue between the Malpighian bodies and convoluted 
tubules, (c.) The epithelium of the renal tubules, and more especially 
that of their convoluted portions, gets cloudy and swollen, and there is a 



ACUTE BRIGHT'S DISEASE. 



741 



tendency to multiplication of the nuclei. Consequently the tubules become 
distended and varicose, their channels get reduced in size or obliterated, 
and their contents acquire unusual opacity. At a later period the cells 
tend to become fatty and to break down, to get separated from one another 
and from the membrane beneath, and to be shed ; and new cells of em- 
bryonic character make their appearance among them. Lastly, the chan- 
nels of the urinary tubules become occupied in a greater or less degree by 
casts, which are either cellular, hyaline, or granular, or consist of blood in 
a more or less altered condition. 

But the diseased kidneys do not always, or indeed generally, present all 
the phenomena above described : and especially it is an important fact, 
that in some the changes, even from the beginning, are mainly epithelial, 
while in others the interstitial tissue is from first to last the chief seat of 
disease. There is a tendency, however, in all cases, especially if they are 
prolonged, for the morbid processes to become generalized. Partly for 
convenience of description, partly because they represent tolerably well- 
defined types, we shall describe three varieties of the disease. 

1. Catarrhal inflammation is the name which may be given to the slight 
and for the most part evanescent affection, which is often met with in 
poisoning by cantharides and other such substances, in connection with 
certain inflammatory or infectious disorders, and under many other cir- 
cumstances. In the first group of cases the tubal affection is associated 
with more or less congestion or inflammation of the mucous membrane Of 
the pelvis, and is for the most part limited to the medulla. In other cases, 
and indeed in most, the cortical tubes are mainly if not exclusively impli- 
cated. The naked-eye appearances are not very striking : there is more 
or less enlargement and softening of the organ ; its capsule can be readily 
peeled off ; the stellate veins on the surface, the Malpighian bodies, and 
the medulla are all more or less congested : while the cortex (if the cortex 
be the main seat of disease) is probably somewhat paler or more yellow 
and opaque than natural. 

2. Another variety is that which arises mainly from exposure to cold 
and wet, and is observed in ordinary cases of acute idiopathic nephritis. 
In this the predominating features are (as in the last case) congestion and 
cloudy swelling of the epithelium. But the congestion is much more in- 
tense and general, and is not unfrequently associated with hemorrhage, 
either into the interstitial tissue, or, as is more common, into the renal 
tubules and Malpighian capsules ; and the cloudy swelling involves the 
contents of all or nearly all the convoluted tubes, and probably in a greater 
or less degree the epithelium of the loops of Henle. The kidney, conse- 
quently, is much enlarged — sometimes indeed to twice its natural bulk — 
and softened ; and its capsule admits of easy removal. The cortex is 
especially thickened. The aspect of the organ varies : in some cases the 
congestion is so extreme and general that the whole of the secreting struc- 
ture, cortex and medulla alike, presents a deep red or claret color ; but 
more frequently the medulla is deeply congested, while the cortex, though 
studded with red points and streaks, is remarkable for its opacity and 
pallor, resembling in this respect a hepatized lung. If the disease persist 
interstitial changes which may at first have been indistinct or absent are 
apt to supervene. 

3. Scarlatinal nephritis differs in many important respects from the last. 
The first observable changes are in the glomeruli, small arteries, and con- 
voluted tubes. The internal elastic lamina of the arterioles, but mainly 



742 



DISEASES OF THE GENITO- URINARY ORGANS. 



of the afferent branches, and the walls of the Malpighian capillaries, 
undergo hyaline thickening, which is attended with more or less complete 
obstruction of their channels ; the nuclei connected with the Malpighian 
tufts (probably the epithelial nuclei) proliferate ; the muscular nuclei of 
the smaller arteries likewise multiply ; and at the same time more or less 
cloudy swelling takes place in the epithelium of some of the convoluted 
tubes. Somewhat later, at the end probably of a week or ten days, other 
phenomena ensue. Lymphoid cells appear in more or less abundance in 
the interstitial tissue, and occasionally in such excess that the diseased 
textures present the characters of adenoid tissue ; and further the epi- 
thelium of the convoluted tubes becomes more generally and distinctly 
swollen and cloudy. The scarlatinal kidney presents much the same ap- 
pearance as that described, but on the whole is generally smaller and less 
congested. 

The results of acute Bright's disease are various. Sometimes at the 
end of a few days, a few weeks, or a few months, the morbid processes come 
to an end, and the kidneys revert to their healthy condition, or to a con- 
dition which is practically healthy but in which a few Malpighian bodies 
and tubes remain permanently atrophic. In other cases the disease be- 
comes chronic, the convoluted tubes remain obstructed by their accumu- 
lated and degenerating contents, or the interstitial nuclear growth changes 
into fibroid tissue, and some one or other of the conditions presently to be 
described ensues. 

Symptoms and progress The symptoms of acute Bright's disease vary 

very much in severity, and are sometimes so trivial as to escape notice. 
Especially this is the case in many febrile and inflammatory disorders, 
where perhaps the only evidence of renal implication is the temporary 
presence of albumen and hyaline casts in the urine. The symptoms ob- 
served in severer cases consist mainly in fever, aching across the loins, an 
abnormal state of urine, and anasarca. The febrile phenomena comprise 
elevation of temperature, sense of chilliness, and occasionally rigors, quick- 
ness, fulness, and hardness of pulse, heat and dryness of skin, flushing of 
face, clamminess of mouth with coating of tongue, thirst, loss of appetite, 
nausea and not unfrequently vomiting, headache, and pains in the limbs. 
From the commencement, probably, the patient notices that his water is 
scanty. A few ounces only may be excreted in the course of the day and 
night ; or there may be complete suppression for many hours. What is 
passed is abnormally dark and often turbid or grumous ; its specific gravity 
is usually high ; it contains abundant albumen, often blood, and a dimin- 
ished quantity of urea; and, microscopically, it presents epithelial, hyaline, 
granular, or bloody casts. It often also contains amorphous urates and 
uric acid crystals. But notwithstanding the scantiness of the urine there 
is generally a constant desire to pass water, and a sense of heat or pain in 
the bladder and urethra. Anasarca comes on early. It usually manifests 
itself first in the face, particularly in the eyelids and conjunctivae, in the 
genital organs, or about the ankles. But it soon becomes general, and 
may become enormous, especially in the specified regions, and in the most 
dependent parts. The surface at the same time tends to assume a peculiar 
pale waxy aspect. Dropsy is not limited to the surface, but takes place 
also into the serous cavities and into the tissues of different internal organs, 
causing, according to its seat, difficulty of breathing or other more or less 
serious consequences. Besides pain in the loins there may be actual ten- 
derness there; and the pain may extend into the thighs as in pyelitis. 



ACUTE BRIGHT' S DISEASE. 



743 



The symptoms, however, are by no means always in accordance with 
the above sketch. Sometimes the anasarca is the first intimation that the 
patient or his doctor has that the kidneys are affected, and it is only on 
further inquiry that the urine is found to be abnormal. Sometimes grow- 
ing anaemia and weakness alone point to the kidney affection, which the 
examination of the urine then detects. Sometimes almost the first indi- 
cation of disease is the presence of palpitation, orthopnoea, and lividity of 
surface, without any discoverable lesion of either the heart or the lungs. 
In some cases the urine is scanty, albuminous, and bloody, and yet no 
anasarca, and scarcely any other indications of impaired health manifest 
themselves. And occasionally also, while all other signs of renal inflam- 
mation are present, the urine remains free from albumen. 

The progress and results of acute nephritis are very various. In a large 
proportion of cases recovery takes place, sometimes in a week or two, 
more frequently at the end of six or eight weeks, occasionally after the 
lapse of six or twelve months or more. The symptoms of returning health 
are chiefly restoration of the functions of the skin, subsidence of anasarca, 
and return of the urine to its normal quantity and character. At the 
beginning of convalescence, indeed, the urine is often in excess. The 
anasarca usually subsides before the urine gets quite free - from albumen. 
It is not uncommon, however, especially after scarlet fever, for anasarca 
to persist even after the urine has become healthy. In a smaller propor- 
tion of cases, but unfortunately in far too many, the affection either ends 
fatally while it is still acute, or assumes a chronic and incurable character. 
The fatal event may occur at different periods, and may depend on one 
or other of the following causes : namely, oedema of vital organs, as of the 
larynx, or lungs, producing dyspnoea, lividity, palpitation, asphyxia ; in- 
flammation of the pericardium, pleurae, lungs, or peritoneum ; anaemia 
and debility ; and, lastly, cerebral symptoms, especially coma and con- 
vulsions. 

TreatmeMt. — In the treatment of acute nephritis it is important to 
assuage if possible the inflammation which is in progress. For this 
purpose we may apply counter-irritants, hot fomentations, or cupping- 
glasses to the loins, or abstract blood by leeches or cupping from the 
same part. The patient should be kept warm in bed and clothed in 
flannel ; warm or hot baths, or the wet-pack, should be occasionally 
administered for the purpose of promoting the action of the skin ; and the 
bowels should be kept moderately free by saline purgatives. The meas- 
ures just enumerated undoubtedly conduce to restore the functions of the 
kidneys, and it is on them we must rely if suppression of urine supervene. 
But, as is strongly urged by Dr. Dickinson, it is important also to remove 
from these organs the solid cylinders which are blocking up the tubules, 
and by their pressure obstructing the efferent veins ; to this end the 
secretion of urine should, if possible, be promoted directly. It is uncer- 
tain how far diuretics are capable of effecting this purpose ; but, at all 
events, it seems judicious to encourage the patient to drink water and 
other simple fluids, and to administer diuretic doses of the acetate or 
citrate of potash or other equivalent medicines. Digitalis is specially 
valuable. At a somewhat later period, when, in addition to other symp- 
toms, anaemia is present, vegetable tonics and the preparations of iron are 
often of great value. The perchloride of iron, which is a diuretic as well 
as tonic, is a favorite remedy. The patient's diet should be nutritious, 
but light, easily digestible, and consisting mainly of milk and farinaceous 



744 



DISEASES OF THE GEN I TO- URINARY ORGANS. 



substances. Alcohol in any form is rarely needed, and generally likely 
to be injurious. If uraemic symptoms supervene active purgation by 
means of elaterium, compound jalap powder, or some other form of drastic 
purgative, should be employed. Other complications must be dealt with 
on general principles. There is a great tendency for nephritis to recur, 
and great care therefore should be taken during convalescence. Iron and 
vegetable bitters, change of scene, and residence in a warm climate are 
often at this time of great service. 



Y. CHRONIC BRIGHT'S DISEASE. 

A. Chronic Parenchymatous or Tubal Nephritis {Large White Kidney 
and Fatty Kidney). 

Causation. — • The causes of the subacute or chronic form of tubal 
nephritis which we are now about to consider are somewhat obscure. In 
a considerable number of cases the disease comes on, so far as we can 
see, spontaneously, or at any rate insidiously. But in some it is directly 
referable to exposure to cold and wet ; and in most cases probably is a 
sequela of the acute inflammatory affections last described. It is a disease 
mainly of early life, seldom occurring under three or over forty. 

Morbid anatomy. — Anatomically the large white kidney is closely 
related to, if it be not identical with, those forms of acute Bright's disease 
in which the pathological changes involve mainly the contents of the 
tubules. In this case as in those, the epithelium is swollen, cloudy or 
faintly granular from the. precipitation of proteinous particles, distends the 
tubes in which it is contained, renders them more opaque than natural, 
and contracts or obliterates their channels ; in this as in those, the axes 
of the tubes become blocked up in a greater or less degree by mucous, 
colloid, or granular casts, while changes in the interstitial tissue are either 
absent or comparatively slight, or come on late. But congestion, which 
is an important condition in the acuter disorder, is absent here. The 
phenomena above described belong mainly to the convoluted tubes, are 
sometimes limited to them, and indeed may involve a certain proportion 
of them only. Not unfrequently, however, they also implicate the loops 
of Henle, and may even' extend into the straight tubes. The Malpighian 
bodies usually remain healthy ; there may, however, be some multiplication 
of the nuclei of the capillaries of the glomeruli, and some degeneration of 
the epithelium investing them. The kidney thus affected is much larger 
than natural, sometimes twice its normal size, soft, and smooth on the 
surface ; and its capsule can be readily removed. Its enlargement is due 
to the increased bulk of the cortex, which is white or yellowish, opaque, 
and sometimes ivory-like. It may be absolutely devoid of blood, or may 
present only a few vascular points and streaks. The medulla for the most 
part remains healthy. Both kidneys suffer. 

With the continuance of the disease changes of more or less importance 
ensue. The swollen epithelium becomes fatty, and tends to break down, 
and when the change is advanced the tubules appear stuffed and opaque 
with fatty detritus. The fatty change may be general, in which case the 
cortical substance acquires a more or less uniform buff color ; or it may 



CHRONIC BRTGHT'S DISEASE. 



745 



be irregularly distributed or more advanced in patches, when the organ 
looks as if it were sprinkled with bran. At this stage the Malpighian 
tufts are often studded with groups of fatty granules, or there is an accumu- 
lation of fatty detritus in the intervals between the tufts and capsules ; 
and occasionally also fatty granules, in more or less abundance, occupy 
the interstitial tissue. The ' branny kidney,' as it is sometimes called, is 
often smaller than the typical ' large white kidney,' and may present an 
indistinctly granular surface. In connection with this fatty change we 
sometimes find distinct increase of the interstitial connective tissue of the 
organ. The kidney then tends to become small, and granular on the sur- 
face, and to present some of the characters of the contracted granular kid- 
ney, which will presently be described. Further, degeneration of the renal 
epithelium occurs in poisoning by phosphorus. It is sometimes also met 
with in diabetes and some other disorders. 

Symptoms and progress. — The early symptoms of the disease under 
consideration vary according to the circumstances under which it is de- 
veloped. If it be a consequence of scarlet fever, or of any other variety 
of acute Bright's disease, the ordinary phenomena of acute nephritis pre- 
cede them, and either at once, or after a series of remissions and exacerba- 
tions, merge into them. A common history is that the patient after some 
acute attack gets apparently well, but does not wholly lose his albuminuria ; 
and that he continues fairly well, but with persistent albuminuria, or in- 
termittent attacks of it, until at the end perhaps of some years character- 
istic symptoms come on. If it be of acute origin, lumbar pain, febrile 
phenomena, and smoky urine are amongst its primary symptoms. But 
whenever the disease comes on as a late sequela of some acute form of 
nephritis, or independently of present inflammation, its symptoms creep 
on gradually. They are mainly scanty excretion of urine, rapid occurrence 
of general dropsy, and speedy manifestation of anaemia. In the early 
stage of the disease the urine is always diminished in quantity; not infre- 
quently three or four ounces only are passed in the twenty-four hours ; 
and occasionally there is temporary suppression. Yet there is generally a 
good deal of irritability of bladder, and frequent desire to micturate. The 
urine, besides being scanty, is dark-colored, of high specific gravity, and 
deposits a more or less copious sediment. It contains a large quantity of 
albumen, and, under the microscope, presents more or less abundant casts, 
which are for the most part mucous or colloid, and if fatty changes have 
occurred granular, or studded with oily matter or invested in fatty debris. 
Sometimes the casts are few in number or altogether absent. Uric acid 
crystals are often present, and sometimes very numerous and large. Urea 
is much diminished. Dropsy always comes on early, and soon becomes 
general and abundant, and although liable to vary somewhat in degree, is, 
on the whole, very persistent. With the increase of dropsy the surface 
gets more and more pale and waxy-looking. The gradual supervention of 
anaemia is generally a striking feature of the disease. This is in part 
apparent only, and due to the presence of anasarca ; but it is referable 
mainly to actual deterioration of the blood determined in some degree by 
the daily abundant loss of albumen. As in ordinary anaemia, persons with 
delicate skin not unfrequently display a fallacious appearance of bloom in 
the cheeks. Together with the above symptoms patients suffer more or 
less from debility, restlessness, dyspnoea, loss of appetite, vomiting, and 
other symptoms of gastro-intestinal disturbance. Among the sequelae or 
complications of the disease the following may be enumerated : Dropsical 



746 



DISEASES OF THE GENITO- URINARY ORGANS. 



effusion into the pleurae, lungs, or glottis ; inflammation of the lungs, 
pleura?, pericardium, or peritoneum ; erythematous, erysipelatous, or gan- 
grenous inflammation of the dropsical skin, more especially that of the 
lower extremities and external genital organs ; hypertrophy of the heart — 
this is no doubt much less marked and less common than in chronic inter- j 
stitial nephritis, but it certainly not unfrequently takes place when the 
disease is much prolonged ; albuminuric retinitis — this again is a much 
rarer phenomenon in parenchymatous nephritis than in connection with 
the contracted granular kidney, yet it is occasionally observed, and may 
be so extreme and attended with so much hemorrhage as to render the 
patient almost absolutely blind. Lastly, urasmic symptoms are not infre- 
quent, especially headache and sickness, followed by convulsions or coma. 

Patients may of course recover from this disease, and the milder the 
attack the more likely is recovery to ensue. Favorable symptoms are : , 
Increase in the amount and diminution in the specific gravity of the urine, 
with disappearance of albumen, restoration of the functions of the skin, 
and subsidence of dropsy. Casts may continue in the urine after albumin- 
uria has ceased. If a cure take place it is generally within six months. 
Recovery is in many cases fallacious ; the patient improves to a certain 
point only — it may happen indeed that both albuminuria and dropsy dis- 
appear — and then after remaining pretty well for a time he has a relapse 
of which he dies ; or the disease is prolonged by alternate remissions and 
relapses for several years. Death usually occurs in from three to twelve 
months, generally within six, either from extreme asthenia or from one of 
the complications which have been enumerated. "But if we reckon the 
duration of the disease from the scarlatinal or other acute affection to 
which it may have been remotely due, it must be measured by years, and 
may be as much as ten or fifteen. 

B. Chronic Interstitial Nephritis. (Contracted Granular Kidney. Gouty 

Kidney.) 

Causation Chronic interstitial nephritis is more common in men than | 

in women, and is met with almost exclusively in advanced life. It rarely 
occurs under forty years of age. The causes which determine it are not { 
well understood. There is reason to believe that the tendency to it is 
sometimes hereditary. It is certain, too, that it is often combined with 
wide-spread changes of a similar kind in other organs. It is frequently 
associated with gout, and there is some obscure but undoubted connection 
between it and chronic lead-poisoning. Alcohol has certainly not the 
same tendency to produce this state of kidney that it has to cause cirrhosis 
o^ the liver. Nevertheless, there is good reason to believe that a small 
number of cases may be referred to abuse of drink. Again, it must we 
think, be admitted, that the various inflammatory affections of the kidney 
already described, especially that originating in scarlet fever, and paren- 
chymatous nephritis, tend in the course of years to produce a contracted 
granular condition of the organ, scarcely if at all distinguishable from that 
due to primary interstitial nephritis. 

Morbid anatomy. — The contracted granular kidney is in distinct ana- 
tomical relation with the scarlatinal kidney, inasmuch as in both of them \ 
the morbid process commences in and implicates essentially the renal ves- 
sels and interstitial texture — the affection of the tubules and of their con- 
tents being secondary. Nevertheless, it cannot be pretended that they 



CHRONIC BRIGHT'S DISEASE. 



747 



usually staud to one another in the relation of cause and effect. The typical 
contracted granular kidney is much smaller than the healthy organ, and 
occasionally not more than an ounce or half an ounce in weight. Its cap- 
sule is adherent, and on removal apt to carry with it small portions 
of the cortical substance. The surface is nodulated like that of a cirrhosed 
liver (the nodules being perhaps as large as hemp seeds) and of a deep 
reddish hue. On section the cortex is found to be much reduced in thick- 
ness, the medulla atrophied though in a less degree, and the texture of the 
organ generally dark colored and dense. Cysts of various sizes, and in 
more or less abundance, are often observed studding the secreting structure, 
but more especially the cortical portion. On microscopic examination, the 
Malpighian bodies are seen to be largely changed, they are much reduced 
in size, their capsules are thickened and laminated, and their capillary 
tufts are welded into almost homogeneous lumps ; the convoluted tubes are 
more or less atrophied, sometimes denuded of epithelium or lined with 
embryonic cells, sometimes stuffed with fatty contents, sometimes filled 
with hyaline casts, sometimes reduced to fibrous filaments or bands, 
scarcely distinguishable from the surrounding tissues, sometimes converted 
into microscopic cysts lined or not with distinct epithelium ; the loops of 
Henle and the straight tubes show less important changes, nevertheless 
their epithelium may present more less fatty degeneration, they may be 
blocked up with hyaline casts, and occasionally some of them are converted 
into strings of cysts ; the vessels, more especially the arteries, are much 
thickened, and at the same time reduced in calibre, while the larger ones are 
probably also atheromatous ; and finally, the connective tissue of the organ 
is more or less extensively hypertrophied. This fibroid growth occurs 
mainly along the interlobular vessels, extending vertically from the sur- 
face to the junction of the cortex and medulla, and thence spreads hori- 
zontally so as to involve in the first place, and most importantly, the im- 
mediately contiguous Malpighian bodies and convoluted tubes, leaving the 
straight tubes which occupy the centres of the lobules comparatively free. 
This distribution explains both the special atrophy of the Malpighian 
bodies and convoluted tubes, and the granular condition of the surface of 
the organ — the depressions corresponding to the intervals between lobules, 
the elevations to the comparatively healthy central portions which contain 
the straight tubes. In the early stage of the disease, as in the early stage 
of cirrhosis of the liver, the kidney is little if at all diminished in size, 
the granulations on the surface are absent or only slightly developed, and 
a new growth of embryonic tissue may be observed in all those regions 
which subsequently undergo contraction and atrophy. The changes above 
described occasionally affect limited parts of otherwise healthy kidneys ; 
and often manifest themselves ultimately in the attenuated and compressed 
kidney- structure, seen in advanced hydro-nephrosis. Further, as has already 
been pointed out, the fatty and granular conditions are not unfrequently 
associated. In which case the kidney is larger and more irregular in form 
than the simple granular kidney ; its superficial granules are larger and 
paler ; and its cortex is mottled with whitish and yellowish patches, due to 
area? of fatty degeneration. 

The cystic kidney — There is probably no essential distinction between 
the cystic kidney and that which has just been described, notwithstand- 
ing that the former may attain the bulk of a bullock's kidney, and the 
latter is usually unnaturally small. It has been mentioned that in the 
granular kidney obvious cysts are of common occurrence. There is no 



748 DISEASES OF THE GENITO-URINARY ORGANS. 



limit, indeed, to their size and nnmber ; the cause which produces them at 
one or two points in one case may be in general operation in another case, 
and hence, in place of half a dozen we may have hundreds or thousands ; 
and instead of being no larger than a pea or marble many of them may 
attain the size of a pigeon's egg or a still greater bulk. In some of the 
more remarkable cases of this kind the kidney during life constitutes an 
easily recognizable tumor, and post mortem may have the aspect of a mul- 
tilocular ovarian growth — consisting of little else than a congeries of cysts, 
probably measuring seven or eight inches in length, and weighing between 
two and three pounds. The contents of the cysts vary in character even 
in the same case. They are sometimes limpid, sometimes thick and treacly, 
sometimes solid and jelly-like. They may be colorless or straw-colored, 
or may present any tint between this and a dark brown or red. They 
may be clear, turbid, or opaque. They usually contain more or less al- 
bumen and the ordinary salts of the serum of the blood, but rarely if ever 
any special urinary constituents. The more viscid accumulations prob- 
ably contain colloid matter. Among microscopic constituents are observed 
in different cases granular or fatty matter, disintegrating cells, decomposing 
blood, and cholesterine. Further, the cysts are often lined with pavement 
epithelium. There is reason to believe that they originate both in Mal- 
pighian bodies and in portions of renal tubules which, owing to inflamma- 
tory or degenerative changes, have been cut off from their connection with 
the rest of the secreting structure of the kidney. The abundant micro- 
scopic cysts observed in many cases of granular kidney certainly originate 
in convoluted tubules which, losing their epithelium and undergoing de- 
generation, become obliterated at points, distended in the intervals, and 
thus acquire a moniliform character. Another view, originally proposed 
by Mr. Simon, is that they arise in extravasated and overgrowing or drop- 
sical renal epithelial cells. 

It is a curious fact that in some of the most typical cases of cystic 
kidney similar cysts have been abundantly present in the liver. 

Symptoms and progress. — The symptoms of granular kidney usually 1 
come on insidiously, and do not attract notice until the disease has made 
considerable progress. Indeed, it often happens that it is the occurrence 
of some complication that first calls attention to the presence of renal mis- 
chief. The patient, who had formerly enjoyed good health, gets thin, 
weak and anosmic without obvious cause ; he suffers from dyspepsia, has 
loss of appetite, nausea, and perhaps actual sickness; he complains of 
shortness of breath and palpitation ; he is liable to bronchitic attacks ; his j 
eyesight becomes impaired ; and he probably notices that he makes more 
water than he was accustomed to make, and that he has to get up several 
times in the night to pass it. At length he seeks medical advice, and the 
urine is found to be of persistently low specific gravity, and probably to 
contain more or less albumen. In other cases attention is first seriously 
directed to the patient's condition in consequence of puffiness of the con- 
junctivae or eyelids, or swelling of the legs or scrotum. In other cases, 
again, the first clear intimation of disease is the supervention of severe 
sickness or diarrhoea, or paroxysms of extreme dyspnasa, or oedema of the 
larynx, or the development of tremors not unlike those of paralysis agitans, 
or attacks of sudden blindness without visible optic changes and tending 
to remit, or ursemic convulsions, or an apoplectic seizure. [The presence 
of persistent headache, which cannot be otherwise explained, especially if 
the pain be referred to the vertex, should always arouse suspicion as to 



CHRONIC BRIGHT'S DISEASE. 



749 



the possible existence of granular degeneration of the kidneys.] The 
early symptoms, indeed, which are also in many respects those of the 
established disease, are multiform ; and they are frequently masked by 
the presence of associated visceral lesions, more especially of the heart, 
lungs, liver, intestinal canal, and brain. Nevertheless there are certain 
phenomena which are specially characteristic of the disease and indicate 
its presence, and to these we will now direct attention. 

The urine is almost always abundant, pale, limpid and acid. Three 
or four pints, or even eight or ten, may be passed habitually during the 
twenty-four hours. Its specific gravity is low, varying from about 1003 
or 1004 to 1010 or 1012, and it contains but little urea or other normal 
urinary constituents. Nevertheless the total amount of urea discharged 
daily is often fully up to the normal standard. Albumen, though gene- 
rally present, is in small proportion. It is sometimes, however, in excess ; 
sometimes wholly absent. Microscopic casts, too, are scanty, and may be 
readily overlooked ; they are for the most part hyaline and granular. 
The condition of the urine may, however, vary; sometimes because the 
renal disease is not one of pure interstitial nephritis, sometimes as a conse- 
quence of temporary congestion or inflammation ; and late in the disease 
it is apt to become scanty, of comparatively high specific gravity, and at 
the same time deficient in urea. Dropsy, so common in other forms of 
Bright's disease, is often absent in this; and even when present, is for the 
most part slight and variable and of late occurrence. It is sometimes 
limited to the conjunctiva?. But occasionally it becomes extreme ; and 
especially in those cases where also the urine becomes scanty, and mainly, 
therefore, towards the close of life. It is in association with the con- 
tracted granular kidney that thickening of the walls of the small arteries 
and hypertrophy of the heart mainly occur. The degree of these changes 
is generally proportioned to the length of time during which the renal dis- 
ease has been in progress, and the degree to which the kidneys have 
shrunk. The hypertrophic condition of the heart is generally revealed by 
its heaving pulsation and increased area of dulness ; and the general arte- 
rial affection by heightened tension of the larger arteries and incompressi- 
bility and prolonged tidal wave of the pulse. At a late period, however, 
the heart becomes enfeebled. 

In association with the continuance of the conditions here discussed, the 
patient becomes more and more enfeebled and incapable of exercise, and 
probably emaciates ; he complains of dryness of mouth or thirst, loss of 
appetite, flatulence and nausea, and especially at a late period of constant 
and distressing sickness; his bowels probably are variable; he has attacks 
of difficulty of breathing, coming on mainly at night time, and presenting 
a good deal of resemblance to those of ordinary asthma ; he suffers also 
from headache, giddiness, or sense of oppression or weight, is often dis- 
posed to somnolence, and becomes apathetic. His skin is harsh and 
unperspiring, and his complexion probably sallow ; but he rarely becomes 
distinctly anaemic, or suffers from lumbar pain. 

Many complications are apt to arise in the course of the disease, and 
especially towards its fatal close. Inflammatory affections are common, 
more particularly inflammation of the pericardium and pleura?, oedema of 
the glottis, bronchitis, and pneumonia. Functional nervous disorders are 
extremely common, and among the most characteristic of them. They 
comprise (besides headache, somnolence, tremors, sickness, and, we may 
add, delirium) epileptiform attacks or coma, which are frequently preceded 



750 DISEASES OF THE GENITO- URINARY ORGANS. 



by these or other nervous phenomena, and attacks of amaurosis without 
obvious affection of the eyes, which are apt to come and go, but after a 
time to end in absolute blindness. Affections referable to the circulatory 
organs, again, are of frequent occurrence ; epistaxis and bleeding from the 
stomach and bowels and other mucous membranes are often observed; 
retinal hemorrhage or albuminuric retinitis is far more common in this 
than in any other form of kidney disease, and is not unfrequently one of 
the earliest indications of its presence ; in addition to the characteristic 
thickening of the smaller arteries, atheromatous and calcareous changes of 
the arterial system are commonly present, and partly from this cause, 
partly from excessive blood-pressure within the vessels, hemorrhagic effu- 
sion into the substance of the brain is very liable to occur; again, thrombi 
are apt to form in the pulmonary arteries, leading to pulmonary apoplexy, 
and also in the systemic vessels and cavities of the heart. Lastly, it may 
be observed that granular degeneration of the kidneys is occasionally asso- 
ciated with similar disease in the liver and other organs, and that dysen- 
teric ulceration not unfrequently supervenes. 

Chronic interstitial nephritis is essentially a disease of long duration. 
It may certainly continue for ten years or more. The causes of death 
have been sufficiently indicated in the last paragraph ; but the most fre- 
quent cause is uraemic poisoning, sometimes with convulsions, more fre- 
quently with coma. 

C. Treatment of chronic Brighfs Disease. 

The treatment of chronic parenchymatous nephritis is essentially the 
same as that of the acute disorder. Abstraction of blood, however, is less 
likely to be required. Perspiration should be promoted by the measures 
previously discussed or by the Turkish bath. The bowels should be kept 
freely open by saline purgatives. Diuresis should be solicited by bland 
drinks, alkalies, and digitalis. Moreover the stimulant diuretics, broom, 
juniper, squill, and nitric ether, which are unsuitable in the acute disease, 
may be given with advantage here. The rapid development of anaemia : 
points significantly to the use of iron, and there is no doubt that ferruginous 
preparations, and especially the perchloride of iron, are more valuable in 
this than in any other form of nephritis. 

In dealing with cases of granular disease the incurability of the lesion 
must not be forgotten. If no special symptoms are present it may be 
desirable to promote the action of the skin by the wearing of flannel and 
the use of baths, to keep the bowels open by occasional mild purgatives, to 
give tone to the system by the employment of iron in combination with 
vegetable bitters, and to support strength by wholesome nourishing diet, 
not superabundant in quantity, and comprising a small proportion only of 
animal food. Late in the disease, when the urine becomes scanty, and 
dropsy or indications of uraemia present themselves, the promotion of urine 
and drastic purgation are called for. 

In all forms of chronic Bright's disease special symptoms require to be 
treated as they arise. For dropsy the most effectual remedial measures 
have already been enumerated. But when the accumulation of fluid is 
extreme it may need to be removed by surgical means. For this purpose 
'acupuncture' or the puncture of the skin with a needle in several places 
just above the ankle, or in the scrotum or some other dependent part, may 
be performed, or incisions may be made in the same localities. Or better 



CONGESTION OF THE KIDNEY. 



751 



still, a fine trocar and canula (according to Dr. Souther's suggestion) may 
be inserted, and retained in situ for some days without inconvenience. It 
must not be forgotten, however, that erythema and sloughing are apt to 
follow this slight operation, apparently from the irritating effects of the 
escaping serum on the integument over which it flows. To avert this 
danger it is well io anoint the surface previously with sweet oil. Ureemic 
poisoning may often be obviated or cured by the use of drastic purgatives. 
When convulsions are present the inhalation of chloroform often affords 
relief. It is needless to lay down rules with regard to the treatment of 
urosmic asthma, ursemic dyspepsia, and the many other complications of 
chronic Bright's disease. 

In all cases when either convalescence is in progress or the symptoms are 
of a chronic character hygienic and tonic treatment is of the highest im- 
portance, and especially residence in a genial climate ; moderate out-of- 
door exercise stopping short of fatigue, wholesome unstimulating diet and 
early hours are likely to be beneficial. 

In conclusion it may be pointed out that in all varieties of Bright's dis- 
ease the use of certain drugs is fraught with danger. Of these, opium, 
mercury, and cantharides are the most important examples. 



VI. CONGESTION OF THE KIDNEY. 

Causation — Congestion is present in a greater or less degree in all in- 
flammatory affections of this organ, in many febrile diseases, and as a con- 
sequence of the action of certain irritant poisons. The form of congestion, 
however, which we are -now about to consider is that passive congestion 
which arises in the course of obstructive cardiac and pulmonary diseases. 

Morbid anatomy. — This condition is characterized in its early stage by 
congestion, enlargement, and softening of the kidneys. The veins are 
especially overloaded, and more particularly the stellate veins of the outer 
surface and those of the medulla. If the congestion continues, induration 
takes place, due to slow increase of the interstitial fibrous tissue of the 
organ, and ultimately more or less atrophy of the Malpighian bodies and of 
the other secreting elements, including fatty degeneration of the cortical 
epithelium. 

Symptoms — In this affection there is not generally much to attract 
attention to the condition of the kidneys beyond scantiness of urine, and 
the presence in it of albumen, and occasionally of blood, and of casts which 
are hyaline or granular, or formed in part or wholly of disintegrating 
blood-corpuscles. The albumen is generally scanty, but sometimes it is 
very abundant. The specific gravity is usually high. Inflammation 
readily supervenes. As a rule the general symptoms due to renal conges- 
tion are so inextricably intermingled with those of the disease to which 
the congestion itself is due, and which in fact they closely resemble, that 
they do not admit of separate recognition. Occasionally, however, unemic 
poisoning and other common consequences of Bright's disease are distinctly 
developed. 

The treatment is mainly that of cardiac or pulmonary disease, as the 
case may be ; and the employment of remedies calculated to relieve renal 
congestion, more especially purgatives, diaphoretics, and unirritating 
diuretics. 



752 



DISEASES OF THE GENITO - URINARY ORGANS. 



VII. TUBERCULAR DISEASE OF THE KIDNEY. 

Morbid anatomy — For the most part tubercles are developed in the 
kidney as a comparatively late event of general tuberculosis, give rise to 
few or no symptoms, and are of little clinical importance. Sometimes, 
however, tuberculosis is primary in the kidneys, or at all events may be 
found post mortem to be far advanced in these as in other organs ; and 
under such circumstances the renal affection is a material, possibly the 
chief, item of the patient's illness. When tubercles are abundant and far 
advanced in the kidneys, they are probably always present also in the 
mucous membrane of the urinary organs — pelves, ureters and bladder — 
and even in the vesicular seminales and testes, or in the uterus and Fallo- 
pian tubes. 

Tubercles appear in the first instance as gray granulations scattered 
mainly in the cortex, but occurring also in the medulla. It is in this form 
that they are generally discovered. After a while they increase in number 
and in size, coalesce into larger masses, undergo caseous degeneration, 
soften, and perhaps suppurate. 

Under such circumstances the kidney may become considerably enlarged, 
riddled with cavities of various sizes containing either cheesy matter, 
tubercular detritus, or pus, and studded in the intervals with unsoftened 
tubercles. The destructive process may proceed so far, indeed, that the 
whole of the secreting structure becomes converted into a series of large 
tubercular cavities, of which one corresponds to each cone and its asso- 
ciated portion of cortex. These cavities may either communicate by 
ulceration with the pelvis of the kidney, or remain .separated from it, in 
which case the contents change after a time into a creamy or mortary 
material like that already adverted to as due to the drying up of ordinary 
renal abscesses. 

Tubercles affect the mucous lining of the pelvis and ureter in precisely 
the same way as they affect other such surfaces ; miliary granulations 
appear in scattered groups in the substance of the membrane, become 
caseous, and then disintegrate, producing shallow circular pits, the surfaces 
of which generally present more or less tubercular detritus. The junction 
of neighboring pits leads to a greater or less extent of superficial destruc- 
tion, and the formation of an irregular sinuous- edged ulcer. There is 
generally also more or less thickening of the subjacent and surrounding 
tissues. The pelvis generally becomes dilated. The ureter, on the other 
hand, usually gets narrowed or even obliterated. 

Symptoms and progress In considering the symptoms of renal tuber- 
culosis it is almost impossible to separate them practically from those due 
to the associated affection of the urinary passages ; and it is not difficult to 
surmise what the main symptoms of these united conditions must be. They 
are, indeed, essentially those of chronic pyelitis ; and comprise pain and 
tenderness in the loins, tumor possibly, irritability of bladder with perhaps 
pain or scalding in passing water, and the discharge of urine containing a 
greater or less abundance of mucus, but more generally pus, and occa- 
sionally it may be a little blood together with debris of tissue. The urine, 
is said generally to be scanty, and not to contain renal casts ; but the dis- 
covery of casts must not be taken to disprove the presence of renal tubercle, 
nor is the scanty secretion of urine by any means constant. The reaction 
of the urine is for the most part slightly acid ; but, as in cases of non- 



MORBID GROWTHS OF THE KIDNEY. 



753 



specific pyelitis and cystitis, is apt to become alkaline from decomposition. 
The course of renal tuberculosis is essentially unfavorable ; for, indepen- 
dently of the slow but sure destruction of the renal tissue, which must 
ultimately lead to a fatal result, the local disease sooner or later becomes 
associated with the development of tubercles in other organs. The symp- 
toms and progress of any case will necessarily vary according as the phe- 
nomena due to the urinary apparatus or those referable to implication of 
other organs preponderate. It is important to bear in mind that the 
symptoms of renal tubercle and of tubercle of the urinary passages are not 
in any sense specific ; and that their diagnosis must mainly rest on the 
detection of similar disease in the lungs or elsewhere. 

Treatment The treatment of renal tubercle comprises that of tuber- 
culosis and that of chronic pyelitis. 



VIII. SYPHILITIC DISEASE OF THE KIDNEY. 

Lardaceous infiltration of the kidney is a common attendant on ad- 
vanced syphilitic cachexia ; but specific syphilitic affections of this organ 
are exceedingly rare. Very few cases of distinct gummatous tumors are 
recorded ; but occasionally, on examining the bodies of persons who have 
suffered from syphilis, and in whom gummata or their remains are visible 
in other organs, the surface of the kidney presents well-marked linear and 
stellate depressions corresponding to localized induration and atrophy of 
, tissue. These are most likely of syphilitic origin ; but have probably 
never given any indication during life of their presence. As regards 
diagnosis, all that can be said is that when patients with advanced syphilis 
present symptoms indicative of renal disease, they are probably due to 
lardaceous infiltration, but may possibly result from the formation of 
gummata. 



IX. MORBID GROWTHS OF THE KIDNEY. 

Morhid anatomy Several varieties of tumor are met with in the 

kidney. Fibromata sometimes attain a large size, so large, in fact, as to 
be easily recognizable during life. But they do not, so far as we know, 
produce any inconvenience or symptoms beyond such as depend on their 
situation and bulk. The only tumors that have any practical interest are 
those possessing malignant properties. 

1. Lymphadenoma generally occurs in the kidney as a secondary or late 
event in the gradual generalization of the disease. The renal growth 
occurs in patches which at the surface of the organ are circular, pale, and 

' scarcely elevated, and are prolonged into its substance in a wedge-like 
I form. Other patches are wholly imbedded in the substance of the organ. 
| On microscopic examination the cells which constitute the growth are 
i found to occupy the intertubular spaces only — the tubules and Malpighian 
j bodies, which may remain healthy, being surrounded and separated from 
one another by them. 

2. Sarcoma has occasionally been observed in young children. It is 

48 



I 



754 



DISEASES OF THE GENITO-URIN AR Y ORGANS. 



probable, however, that many infantile renal tumors, which have been 
described as cancerous, were really examples of sarcoma. The disease 
seems to attack one kidney only, to cause enormous enlargement of the 
organ, and to be undistinguishable during life from cancer. 

3. Carcinoma may be primary or secondary. When secondary it rarely 
attains large dimensions ; when primary it is generally limited to one 
kidney, and this soon forms an enormous tumor. Renal carcinoma is, 
almost without exception, of the encephaloid variety, and usually highly 
vascular. It commences in the form of one or more isolated tumors, 
which gradually invade the adjacent renal structure until the greater part 
or the whole of the organ is involved. While this process is going on the 
kidney becomes enlarged, but still probably on section presents the out- 
lines of its original divisions. With the continuance of the growth, how- 
ever, all traces of renal structure get obliterated, and the kidney is con- 
verted into a simple carcinomatous mass, still probably presenting the form 
of the healthy organ, but attaining the size it may be of a cocoa-nut or 
large melon, and weighing several or many pounds. In the progress of its 
growth it becomes adherent to surrounding tissues and organs which may 
then be involved by continuity ; and it develops nodular, papillary, or even 
villous outgrowths into the cavity of the pelvis and infundibula. The car- 
cinomatous kidney is of course liable to all those changes which generally 
characterize carcinoma ; it presents consequently, in addition to growing 
tissue, patches or networks of caseous and fatty degeneration, hemorrhagic 
effusions, and tracts of liquefaction. The ureter is not unfrequently in- 
volved, and even when not distinctly cancerous, is apt to become thick- 
ened and more or less completely occluded. 

Symptoms and progress The recognition of secondary growths in the 

kidney, whether they be lymphoid, sarcomatous, or cancerous, is a matter 
of little importance ; and that of primary carcinoma is, until the disease 
is far advanced, often extremely difficult. The chief circumstances to be 
taken into consideration in forming a diagnosis are : first, the very gradual 
development of symptoms ; second, the frequent discharge of blood in 
quantity with the urine ; third, the gradual formation of a tumor in the 
situation of the kidney ; fourth, the appearance of secondary cancerous 
growths ; and, fifth, the occurrence of progressive emaciation, debility, 
and cachexia. The symptoms, in fact, are mainly those common to can- 
cerous growths, together with such as depend on the situation of the tumor, 
and modification of the urinary secretion. Of these three symptomatic 
groups the latter two only call for further remark. The development of 
cancerous tumors is sometimes painless ; sometimes, on the other hand, 
the patient suffers from frequent paroxysms of the most intense agony ; 
and generally sooner or later there is manifest local tenderness. The 
tumor is characterized by originating deep in the lumbar region ; and (as 
it grows and fills more or less of the abdominal cavity) by its position, by 
its fixation, by its general rounded form, and very importantly by the fact 
that it is almost invariably crossed by the ascending or descending colon, 
the presence of which may often be seen, and always recognized by per- 
cussion. The veins in the abdominal walls on the affected side are often 
much dilated ; and not unfrequently from the pressure of secondarily 
affected glands, oedema of the corresponding lower extremity or of both 
extremities comes on. A cancerous kidney generally feels hard, but is 
sometimes yielding, and may be so soft as to give a deceptive sense of 
fluctuation. It often enlarges so greatly as to fill its own side of the abdo- 



PARASITIC AFFECTIONS OF THE KIDNEY. 



755 



men, and occasionally not only fills this, but encroaches to a great extent 
on the opposite side. It has been pointed out that the urine often contains 
blood. Hemorrhages occur at irregular intervals, and are sometimes so 
profuse and frequent as to blanch the patient. It must not be forgotten, 
however, that in many cases no hemorrhage whatever takes place; and 
that in many the urine from first to last is perfectly healthy. The latter 
circumstance is in' great measure due to the fact that the ureter of the 
affected side often becomes impervious even at an early stage of the dis- 
ease. Cancer-cells rarely if ever find their way from the kidney into the 
discharged urine, and, even if present there, would probably be undistin- 
guishable from the epithelial cells of the bladder. The affection with 
which renal cancer is most apt to be confounded is renal calculus associated 
with pyelitis and distension of the cavity of the kidney. 

The liability to error is increased when gravel or small calculi are, as is 
not uncommon, present in the pelvis of the cancerous organ. In the early 
stages of cancer, indeed, it is often impossible to discriminate between it 
and calculous pyelitis. Later on its recognition is more easy, but then the 
diseased organ is apt to be mistaken for an ovarian, splenic, or hydatid 
tumor. 

Treatment In the treatment of renal cancer there is nothing to be 

done beyond endeavoring to relieve the patient's symptoms. Opiates are 
here invaluable. 



X. PARASITIC AFFECTIONS OF THE KIDNEY. 

Animal parasites seldom affect the urinary organs, at any rate in tem- 
perate climates. The Strongylus gigas and Pentastoma denticulatum have 
been so rarely observed in the kidney that no practical interest attaches to 
them. Hydatids are much more frequently met with there, and the Bil- 
ftarzia hcematobia is common in the vessels of the urinary organs in cer- 
tain tropical countries. Of the Filar ia sanguinis hominis in relation to the 
urinary organs, we shall speak under the head of chyluria. 

A. Hydatid cysts of the kidney are far less common than hydatid cysts 
of the liver. Still many authentic cases are on record. The anatomical 
characters, progress, and consequences of renal hydatids present nothing 
distinctive beyond the facts that the enlarging cysts have the usual situa- 
tion and connections of renal tumors, and that they not unfrequently rup- 
ture into the pelvis of the kidney and discharge their contents with the 
urine. It must not be forgotten, however, that hydatid tumors may origi- 
nate in the sub-peritoneal tissue in the neighborhood of the kidney ; and 
that both these and hydatids occupying other situations may open into the 
pelvis of the kidney or into the bladder. If suppuration takes place in 
the cyst of a renal hydatid, the case becomes essentially one of abscess of 
the kidney. 

The treatment of renal hydatids is the same as that of hydatids of the 
liver. 

B. The Bilkarzia hcematobia seems to be the cause of an endemic form 
of hematuria, common in Egypt, at the Cape of Good Hope, and else- 
where. The parasite is of a worm-like form, and three or four lines in 
length. The female is longer than the male, and filiform ; the male is 
comparatively thick, and in the act of copulation incloses the female in a 



756 



DISEASES OF THE GENI TO -URINARY ORGANS. 



gynascophoric canal. It is supposed to be swallowed with the food, and 
thus to gain entrance into the system by the stomach, but it specially in- 
habits the mesenteric veins and those of the large intestine, bladder, ure- 
ter, and pelvis of the kidney. Its presence in the small veins of the 
urinary organs gives rise to lenticular patches of inflammation in the 
mucous membrane, which yield mucus and sometimes blood, ulcerate, and 
discharge shreds of tissue charged with ova. The patient consequently 
presents more or less irritability of bladder, and passes urine containing 
these several ingredients. He often falls also into a state of anaemia and 
debility. When the ureter or renal pelvis is affected, obstruction to the 
flow of urine may arise, pyelitis and hydro-nephrosis may ensue, and the 
patient's symptoms may hence assume a more serious character. The ova 
may form the nuclei of urinary concretions. The presence of these 
creatures in the mucous membrane of the large intestine is apt to produce 
dysenteric symptoms, which, however, are rarely severe. The recognition 
of the disease depends on the discovery of the ova in the urine. 

Treatment It is doubtful if vermifuge medicines are of any efficacy in 

this affection ; injections, however, into the urinary bladder may act bene- 
ficially on so much of the disease as involves that viscus. The forms of 
injection which are beneficial in the treatment of thread-worms naturally 
suggest themselves — namely, bitter infusions, or solution of perchloride of 
iron. Dr. J. Harley prefers solution of iodide of potassium. For general 
treatment, tonic remedies are indicated. 



XI. LARDACEOUS DEGENERATION OF THE KIDNEY. 

Causation — The causes of lardaceous degeneration of the kidney are 
the same as those of lardaceous degeneration of the liver and other organs ; 
and indeed the liver, kidneys, and spleen are generally concurrently 
affected. 

Morbid anatomy The lardaceous kidney increases in size with the 

amount of degeneration present, and may attain a weight of twelve ounces 
or more. When the disease is little advanced it is apt to escape recogni- 
tion by the naked eye ; when, however, it reaches a high degree, the organ 
is somewhat waxy, pale, and homogeneous in texture, and presents a 
slight degree of translucency. The morbid change usually commences in 
the vessels of the Malpighian tufts, but very soon spreads from these to the 
afferent and efferent vessels, the intertubular plexus, the interlobular arte- 
ries, and the vasa recta. The hyaline walls of the urinary tubes and Mal- 
' pighian bodies also suffer, but for the most part somewhat later than the 
vessels. The degeneration here is always most advanced in the large col- 
lecting tubes, and diminishes in degree as one proceeds from these to the 
Malpighian capsules, which in fact generally remain unaffected. The 
epithelial cells are rarely if ever involved, but are often granular, and even 
distinctly fatty. Lardaceous change is apt to be superadded in the course 
of ordinary fatty and granular degeneration of the kidney, in which case 
the several morbid conditions are variously intermingled. Waxy casts 
may generally be detected in both the cortical and the medullary tubules. 

Symptoms and progress — The presence of lardaceous change in the 
kidney does not necessarily give rise to any special symptoms until the 



GRAVEL AND RENAL CALCULI. 



757 



disease is far advanced. The symptoms then, if not of themselves distinc- 
tive, become distinctive when the history of the patient, the condition of 
his other viscera, and his general state are all taken into consideration. 
They are mainly as follow : the urine is increased in quantity, pale, of low 
specific gravity, and poor in urea ; it contains more or less albumen, and 
casts which have not necessarily any special character, but are often waxy, 
yet rarely if ever lardaceous ; micturition is generally frequent ; there is 
often some degree of anasarca, but it is not usually abundant ; and the 
patient is anaemic. In these respects the symptoms are not unlike those 
due to the granular kidney, but the heart does not become hypertrophied ; 
there is absence of arterial tension ; there is little tendency to ursemic 
poisoning ; and, although patients often suffer from serous inflammations, 
inflammation of the lungs, diarrhoea, vomiting, and hemorrhages, these com- 
plications are not distinctly referable to the kidney disease, but are due in 
part or wholly to the presence of associated visceral lesions. 

The treatment of lardaceous kidney is involved in the treatment of the 
affections to which it is secondary. Dropsy and other consequences, 
when they are sufficiently serious to demand separate attention, must be 
treated according to the principles already enunciated under the head of 
chronic Bright's disease. 



XII. GRAVEL AND RENAL CALCULI. 

Causation and morbid anatomy — The presence in the urine, or the 
deposition from it, of uric acid and urates, of oxalate of lime, or of phos- 
phates, is occasionally observed in various morbid conditions of the system, 
and even in states of apparently good health. Such occurrences rarely if 
ever call for medical interference. 

Occasionally, however, the appearance in the urine of one or other of 
these, or of other rarer crystalline matters, persists for some time, or be- 
comes habitual. If under such circumstances symptoms of ill-health mani- 
fest themselves, medical treatment is obviously demanded ; and, indeed, 
even in the absence of symptoms, the danger of the formation of urinary 
calculi is so great that, if the peculiarity of the urine be recognized, it 
should, if possible, be counteracted. 

The amorphous urates are sometimes found deposited in the renal tub- 
ules, but this is probably a post-mortem phenomenon only. Urate of soda, 
in stellate masses of acicular crystals, is now and then discovered imbedded 
in the substance of the kidney; uric acid also, in solitary or clustered » 
crystals, is occasionally detected within the tubules, and again, in the form 
of small calculi, is sometimes found loose in the cavity of the kidney or 
adherent to the mammillary processes. The same may be said in regard 
to the infinitely rarer xanthine and cystine concretions. 

Octahedra and dumb-bells of oxalate of lime, singly or in groups may 
be met with in the urinary tubules, and occasionally also form small calculi, 
which lie loose or adherent within the cavity of the kidney. 

The phosphates are rarely deposited, except in ammoniacal urine, and 
as a consequence of the decomposition of that fluid ; they are, therefore, 
seldom, if ever, detected in the kidney except as secondary deposits around 
nuclei of other matters. Carbonate of lime, however, though much less 



758 



DISEASES OF THE GENITO-URINARY ORGANS. 



frequently forming a urinary deposit, is occasionally met with in the form 
of small laminated globular concretions, either imbedded in the substance 
of the kidney, or free in its pelvis. 

The minuter concretions above described are sometimes discharged with 
the urine in considerable abundance, constituting what is called ' gravel.' 
Small calculi, from the size of a pin's head to that of a horse-bean, are also 
not unfrequently transmitted, with more or less delay, along the ureter to 
the bladder, and thence into the chamber-pot. Sometimes a solitary cal- 
culus is thus discharged, and there is never any recurrence ; sometimes 
large numbers of calculi are discharged at intervals. In other cases these 
bodies remain in the renal' cavity, gradually grow there, and finally, per- 
haps, form a complete cast of the pelvis, infundibuli, and calyces; or a con- 
siderable number of small calculi may become aggregated into that form. 

The presence of calculi in the kidney generally leads to more or less 
pyelitis, and probably at length to abscess, hydro-nephrosis, or some other 
serious consequence. 

Symptoms and progress The symptoms of ' gravel' are : pain of an 

aching or burning character in one or other lumbar region or side of the 
abdomen, probably shooting down to the testis or labium, and along the 
inner aspect of the thigh ; frequent desire to micturate ; soreness or cutting 
pain during micturition, especially at the end of the urethra in passing the 
last few drops ; and nausea and sickness. At the same time the urine is 
generally clear, though it may deposit a greater or less abundance of a 
sand-like sediment, or show microscopic aggregation of crystals, with epi- 
thelial scales. The pain may, of course, affect both sides ; and the patient's 
complaint may be limited to the lumbar or abdominal pain or uneasiness. 

A renal calculus may never reveal its presence by symptoms, and may 
even lead to the disorganization of the kidney without the least suspicion 
of disease having ever been excited. The special indications of the pres- 
ence of a calculus are : first, the occasional occurrence of aching or burning 
pain in the situation of the kidney, resembling, but probably more severe 
than that attending the passage of gravel ; second, the occasional discharge 
of bloody urine ; and, third, the facts that the nephralgia and hematuria 
are often induced by jolting, jumping, and other forms of exercise, and 
that the pain may occasionally be relieved by change of posture. This 
becomes much more intense when the calculus enters the ureter, and con- 
tinues intense so long as the stone is passing along that canal. The pain 
of renal or uretic calculus may be traced along the ureter, shooting thence 
into the loin, radiating throughout the abdomen, and especially extending 
to the thigh, and labium or testis, which last often becomes retracted; it is 
attended with nausea and vomiting, and not unfrequently with rigors and 
, faintness. Jt is often increased by the patient's voluntary attempts to flex 
the thigh on the abdomen. Further, tenderness may exist in the loin and 
along the course of the ureter. The pain due to the transmission of a cal- 
culus begins suddenly, and ends suddenly in a few hours, or after inter- 
missions in the course of a few days, in consequence of the stone becoming 
either arrested in its course or discharged into the bladder. It need 
scarcely be said that the microscopic investigation of the urine often throws 
important light on the diagnosis of cases which come under treatment ; 
and further that, when one kidney has already been destroyed or rendered 
useless, the impaction of a stone in the opposite ureter may cause fatal 
suppression of urine. The symptoms of pyelitis, renal abscess, and hydro- 



GRAVEL AND RENAL CALCULI. 



759 



nephrosis, which are frequent accompaniments or consequences of renal 
calculus, are elsewhere discussed. 

Treatment The treatment of gravel and of renal calculus is for the 

most part identical with that of pyelitis — a subject which has already been 
fully considered. The pain, however, in so-called ' nephritic colic' is 
generally so much greater than in other forms of pyelitis that opium, rest, 
and local measures are all more urgently needed. Opium, especially, is 
our sheet-anchor. As valuable adjuvants we may enumerate purgatives, 
copious enemata, ice-bags, hot applications or cupping to the loins, and 
especially the hot bath. Belladonna is sometimes useful when opium fails ; 
and, when a calculus is descending, may be of » special service in relaxing 
the spasmodic action of the ureter which takes place around it, and im- 
pedes its progress. The removal of a renal calculus by operative measures 
can scarcely be attempted unless the kidney be at the same time in a state 
of suppuration and have formed a manifest tumor. 

In the intervals between the acute attacks, which, from their severity, 
call for special treatment, the question of the removal of the conditions on 
which the gravel or calculi depend presents itself for consideration. Our 
action here must be determined mainly by the nature of the sabulous mat- 
ter which is habitually discharged. 

If uric acid crystals or gravel are passed, it is certain that the urine is 
abnormally acid, and the exhibition of alkalies is demanded. The carbon- 
ate, acetate, and citrate of potash are probably the best for the purpose ; 
and they should be given in such quantities as to render the urine con- 
stantly alkaline. Dr. W. Roberts has shown that the alkaline carbonates 
slowly dissolve uric acid calculi, and that the urine may be rendered and 
kept sufficiently charged with carbonate to produce this effect by adminis- 
tering to the adult forty or fifty grains of the acetate or citrate in 3 or 4 oz. 
of water every three hours. And hence he recommends that, if there be 
reason to believe that uric acid calculi are present in the kidney, the 
patient should be submitted to this alkaline treatment. Phosphate of soda 
also dissolves uric acid, and Dr. Oolding Bird recommends its use in 
scruple or half-drachm doses. It is important at the same time to have 
regard to the patient's mode and habits of life and to any morbid conditions 
which may be present. Thus, valuable indications for treatment may be 
furnished by the fact that he is a bon vivant or of sedentary habits, or that 
he suffers from indigestion or gout. 

Cystine and xanthine deposits and calculi may be treated in the same 
manner as those of uric acid. 

Oxalate of lime, like uric acid, is generally precipitated in acid urine, 
and indeed they are not unfrequently associated. Its presence in small 
quantity is often dependent on the use of certain articles of diet ; when it 
is more abundant and persists, the patient frequently suffers from indiges- 
tion, or presents symptoms of mental depression. The direct treatment of 
oxaluria is not generally very efficacious. The patient's general health 
should be improved by tonic medicines and general tonic treatment, and 
by abstinence, so far as possible, from vegetables containing oxalate of lime, 
and from sugar and other substances which are readily convertible into 
oxalic acid. Nitro-muriatic acid is often recommended; while, on the 
other hand, alkalies seem sometimes to be efficacious. 

Persistent alkalinity of urine from the presence of the fixed alkalies is 
rare, and in itself not very important. It generally seems to be associ- 
ated with some degree of ill-health and cachexia, and may be taken to 



760 



DISEASES OF THE GENITO- UR1 NARY ORGANS. 



indicate the need of tonic treatment and of generous diet. Mineral 
acids, especially the nitro-muriatic, and perchloride of iron, are valuable 
remedies. 

Alkalinity from the presence of carbonate of ammonia is a much more 
serious matter. This always results from decomposition of the urine in 
the urinary channels, is indicative of cystitis or pyelitis, and necessarily 
leads to the deposition of crystalline phosphates. For the relief of this 
condition we must have recourse to the usual treatment of cystitis. 



XIII. HYDRONEPHROSIS AND ATROPHY OF THE 
KIDNEY. 

Causation and morbid anatomy — Whenever any permanent impedi- 
ment to the flow of urine occurs — whether it be in the urethra, bladder, or 
ureter ; whether it be due to a calculus or any other obstacle within ; or 
to some affection of the walls themselves, such as thickening and contrac- 
tion, valvular folds or paralysis ; or to pressure from without, caused by 
ovarian, uterine, or other tumors — the cavities above the seat of obstruc- 
tion dilate and their parietes thicken, and, at the same time, the kidney 
structure becomes expanded and attenuated. The condition known as 
hydro-nephrosis results. If complete obstruction take place, excretion of 
urine continues for a time ; but its accumulation causes more and more 
distension of the renal cavity, and more and more pressure on the renal 
structure, until at length the function of the organ ceases absolutely to be 
performed. In this case, equally with that in which pus accumulates, 
those portions of the renal cavity whose lining membrane is less resistant 
expand most ; and consequently, while the pelvis and infundibula alter 
comparatively little, the calyces dilate until they form a series of sub- 
globular cavities surrounded and separated from one another by atrophied 
kidney structure, and communicating by separate and comparatively small 
orifices with their respective infundibula. When the obstruction is partial 
as well as during that period of total obstruction in which the renal ele- 
ments are still excreting urine, this fluid changes in quality ; it becomes 
less and less rich in solid constituents, pale, watery, and of low specific 
gravity, but remains, for the most part, devoid of albumen. Subsequently 
to the cessation of the proper urinary discharge, the fluid in the cavity may 
still increase in quantity and still undergo changes. Thus, in advanced 
hydro-nephrosis, it is generally watery, but still containing traces of the 
urinary solids ; it is often albuminous ; sometimes charged with decompos- 
ing blood ; sometimes more or less glairy and collodial ; and occasionally 
purulent. After a kidney has become completely hydro-nephrotic and 
ceases to secrete urine, various consequences may ensue. In some cases, 
it remains for a long while almost stationary. In some, the contents be- 
come slowly absorbed and the atrophied tissues shrink and indurate until at 
length a small, hard, lobulated cystic body, weighing perhaps from a drachm 
or two to half an ounce, remains. In other cases, the dropsical kidney 
gradually enlarges until it forms a tumor several times the bulk of the 
healthy organ, and occasionally sufficiently large to fill at least one-half of 
the abdomen. Hydro-nephrosis from total or partial, and often valvular, 
obstruction of the ureter is not unfrequently congenital, and, at the same 



MISPLACED AND MOVABLE OR FLOATING KIDNEYS. 



761 



time, double, and hence hydro-nephrotic tumors are not altogether uncom- 
mon in new-born babes and young children. 

Symptoms and progress. — As a rule, the changes above described creep 
on (if no inflammation ensue) without producing symptoms, and without, 
therefore, calling for treatment. It is comparatively rare for the hydro- 
nephrotic kidney to become so large as to excite observation, still more 
rare for it to become so large as to exert, by its pressure on surrounding 
organs, any deleterious influence. But in these cases alone is diagnosis 
needed, or, indeed, possible. The elements on which an accurate opinion 
must be based are the history of the case, the situation and relations of 
the tumor, its characters as to form, resistance, and fluctuation, and the con- 
stitutional symptoms which are associated with it. In addition to these, 
there is a symptom of rare occurrence, but very characteristic when it does 
occur, and peculiar to cases of incomplete obstruction — namely, the occa- 
sional rapid but temporary subsidence of the tumor, attended with a sudden 
increase in the quantity of urine passed, and some change in its quality. In 
some cases, the dilated organ suppurates, and a renal abscess with the usual 
symptoms of that condition supervene. 

A hydro-nephrotic tumor is liable to be confounded with carcinoma and 
hydatids of the kidney or neighboring parts, and with ovarian cysts. It is 
rarely fatal, except in those cases in which it is double, or where it is asso- 
ciated with other maladies, or where, from, its bulk and interference with 
other organs or from suppuration, slow exhaustion ensues. 

Treatment The treatment is entirely surgical. If manipulation fail 

to drive the contents into the bladder, paracentesis may become necessary. 
To prevent danger from escape of fluid into the peritoneum this operation 
should be performed behind the line of colon which crosses the tumor. 



XIV. MISPLACED AND MOVABLE OR FLOATING 
KIDNEYS. 

Causation and morbid anatomy — Misplacements of the kidneys are 
chiefly important in relation to the diagnosis of abdominal tumors. 
Sometimes, as a congenital peculiarity, one or both kidneys, instead of 
occupying their usual site, lie upon the brim of the pelvis. Sometimes 
one or both of them, though otherwise normally placed, are attached to the 
lumbar region by a peritoneal duplicature or mesonephron analogous to the 
mesentery, or lie freely movable in the lax retro-peritoneal connective 
tissue which surrounds them. Mobility of the kidney is said to be much 
more common in women than in men, and on the right than on the left 
side. Its cause is obscure. It may perhaps in some cases be a congenital 
defect; but it seems also occasionally to follow upon parturition, and pos- 
sibly then to be connected with that general laxity of the abdominal 
parietes which parturition causes. 

There is still considerable doubt on the part of many with respect to 
the occurrence of floating kidney. It is certain there is little post-mortem 
evidence in its favor; and that uterine fibroid and other tumors have been 
mistaken during life for floating kidneys by competent observers. On the 
other hand, it must be borne in mind that such kidneys are probably never 



762 



DISEASES OF THE GENITO- URINARY ORGANS. 



a cause of death. The question has, however, been set at rest affirmatively 
by a recent inquiry made for the Pathological Society. 1 

Symptoms. — The floating kidney projects more than natural (assuming 
an oblique position with the upper end pointing forwards and inwards), 
and is freely movable within narrow limits under the abdominal parietes. 
It may usually be perceived somewhere in the hypochondriac or umbilical 
region, between the navel and cartilages of the ribs ; and if on the right 
side is apt to make its appearance just below the liver and to be mistaken 
for an hepatic tumor. Tf it be grasped, as it sometimes can be, a sicken- 
ing sensation is produced, similar to that which results from squeezing the 
opposite loin ; and sometimes a distinct falling in of the corresponding 
lumbar region with increase of resonance may be clearly recognized. 
From its prominent and pendulous condition it is unduly exposed to pres- 
sure or injury, and consequently is apt to become more or less painful, 
tender, and swollen. 

Treatment When a movable kidney is painful, rest, local applications, 

and the internal use of sedatives may be requisite. To protect it from 
injury, and at the same time to replace it to some extent, an abdominal 
belt may be worn with a concave pad beneath it adjusted to the form and 
position of the kidney. 



XV. CHYLURIA. (Chylous Urine.) 

Causation and symptoms This affection was first recognized and de- 
scribed by Dr. Prout, but since his time has been pretty frequently met 
with and investigated by other observers. It is characterized for the most 
part by the occasional or constant discharge of urine, which is milky when 
passed, coagulates on standing into a tremulous mass resembling blanc- 
mange, and then, becoming again liquid, furnishes a creamy scum and a 
pinkish or brownish sediment. The urine has, in fact, exactly those 
characters which would result from the admixture in varying proportions 
of normal urine and normal chyle. It presents the ordinary urinary con- 
stituents, but in diminished proportion to the whole bulk of fluid. And it 
also contains fibrine, the presence of which explains its spontaneous coagu- 
lability ; albumen, as may be shown by the usual tests ; fat in a molecular 
form, like the fat of chyle, the presence of which accounts for the milky 
character of the fluid when passed, and for the creamy scum; leucocytes; 
and occasionally red corpuscles, to which the colored sediment is partly 
attributable. No casts, however, are ever detected in it ; nor indeed is 
there any other evidence that the chylous material comes from the kidney. 
Further, it often happens in these cases that the urine which is passed is 
not milky, although probably presenting in all other respects the peculiari- 
ties whicli have been enumerated. It is, in fact, lymphous, and not 
chylous ; there is no fat, and the coagulum is transparent like ordinary 
calves'-foot jelly. The presence of tat is, in some instances, observed 
mainly in the morning's yield; more commonly it characterizes the urine 
passed shortly after meals. 

Chyluria appears to be more common in tropical than in temperate 



1 Path. Trans., vol. xxvii. p. 467. 



i 



CHYLTJRIA. 763 

climates, more frequent in adults than in children, and in females than in 
the opposite sex. 

It manifests itself, for the most part, suddenly, is liable to intermissions, 
and occasionally, after lasting some time, disappears for years, or even 
for life. It is attended with no special symptoms, excepting such as 
may result from the continuous drain of nutrient fluid, and those di- 
rectly connected with the condition of the urine and urinary organs ; 
and its presence is compatible with apparent good health and even with 
long life. The characters which the urine presents have already been de- 
scribed ; it may be added that chylous urine not unfrequently coagulates 
in the bladder, causing more or less discomfort and the discharge of 
coagulated material. 

Pathology Dr. Prout attributed the disorder to a combination of two 

circumstances ; — one a defect of assimilation which permitted chyle to 
mingle with the blood without being converted into blood, the other some 
renal default, in consequence of which unchanged chyle was allowed to 
sweat from the kidneys. But the blood has been examined in cases of 
chyluria without the detection of any abnormal chemical constituent in 
it ; and not only, as has been already stated, is there no evidence during 
life to show that the kidneys themselves are diseased, but post-mortem 
examination equally fails to detect any structural change in them. 

Dr. W. Roberts, basing his views partly on a case recorded by himself, 
and partly on one published by Dr. Vandyke Carter, suggested some 
years since an explanation of the phenomena of chyluria which, so far as 
it goes, seems to be correct for at least many cases. In these two exam- 
ples there was chyluria, but there was also on the lower part of the abdo- 
men and in the scrotum, enlargement of lymphatic vessels, with vesicular 
dilatations, which yielded abundance of lymph or chyle — exactly the same 
kind of fluid as that which was passed with the urine. In Dr. Carter's 
patient, the discharge of chyle from the urinary organs and that from the 
skin alternated. Dr. Roberts contended that in these cases the chyle in 
the urine and that yielded by the skin were derived from a common 
source — namely, rupture of vesicular dilatations of lymphatic vessels 
situated on the one hand in the mucous surface of the bladder, or that of 
some other part of the urinary tract, on the other hand, at the cutaneous 
surface ; and he thence argued that chyluria generally depends on a 
similar lymphatic affection of the mucous membrane of the urinary tract. 
The disease, in fact, from this point of view, is identical with what has 
been described earlier in this volume under the name of elephantiasis 
lymphangiectodes. Many other cases of this association have since been 
recorded. 

We have already discussed the interesting discovery by Dr. Lewis of 
the filaria sanguinis hominis in the urine, diseased tissues, and blood of 
patients suffering from chyluria and spurious elephantiasis in India; and 
have shown that there is good reason to believe that the parasite is (at 
any rate in many cases, possibly in all) the essential cause of these two 
affections ; the frequent association of which is thus plausibly explained. 

Treatment — It is needless to enumerate all the remedies which have 
been employed in the treatment of chyluria ; nothing appears to have 
ever been really efficacious, and it is clear, if the explanation above given 
be correct, that nothing, except perhaps rest and astringents locally ap- 
plied, is likely to be efficacious. Tonics may be needed in the anoemia 
which is apt to come on in the course of chyluria. 



764 



DISEASES OF THE GENITO- URINARY ORGANS. 



XVI. HEMATURIA. 

Causation and symptoms — The presence of blood in the urine may be 
due to many different circumstances, but these have already been discussed 
in sufficient detail, and need not be further considered now. 

It is not always possible to ascertain the source or the cause of hgema- 
turia. It may, however, be observed that, if it take place from the sub- 
stance of the kidney, it will almost always be attended with the presence 
of blood-casts, and the urine will generally be more or less smoky ; that, 
if it take place from any of the urinary passages, no casts will be present; 
and that if it be derived from the bladder or urethra, pure unmixed blood 
will probably be occasionally passed, either at the commencement or at 
the end of micturition, or at other times. Further, the more abundant 
the blood is, and the more it exhibits the ordinary characters of blood and 
tends to coagulate, the more likely is it to have been yielded by the urinary 
passages. The hemorrhage which attends simple congestion or inflamma- 
tion of the kidneys or urinary channels is generally scanty. The most 
profuse hemorrhages are usually due to villous or malignant growths of 
the bladder or kidney, or to the effects of renal or vesical calculi. Pro- 
fuse hemorrhage is said also to occur vicariously of menstruation. We 
have previously described the appearance which the urine presents when 
mixed with blood ; and we must refer the reader to other parts of this 
chapter for an account of the lesions of the urinary organs liable to be 
attended with hemorrhage, and for the means by which their respective 
hemorrhages may be distinguished. 

Treatment When the discharge of blood with the urine is scanty and 

of temporary duration, the loss in itself is a matter of little importance, 
and no special anti-hemorrhagic treatment is needed. But persistent 
small hemorrhages, as well as occasional profuse hemorrhages, require if 
possible to be arrested. The patient should be placed in the recumbent 
position, and kept perfectly quiet and cool. He should have ice to suck, 
or be supplied with cold drinks in small quantities. In addition, it is 
advisable to give by the mouth some form of astringent medicine, such as 
turpentine, gallic acid, or some other vegetable astringent, lead, perchlo- 
ride of iron, or a mineral acid. But probably more valuable than any of 
these is ergot or digitalis. If there be reason to believe that the bleeding 
is taking place from the kidneys, ice or cold compresses may be applied 
to the loins ; if from the bladder, similar applications may be made to the 
perineum or hypogastrium, and either cold water or solutions of perchlo- 
ride of iron or tannic acid may be injected into the bladder. 



XVII. PAROXYSMAL HEMATURIA. (Paroxysmal Hcematinuria.) 

Definition This is a remarkable affection, which was first distinctly 

described a few years since by Dr. G. Harley, and of which many cases 
have since been recorded. It is characterized by the sudden occurrence, 
at more or less irregular intervals, of severe rigors, followed by the dis- 
charge from the kidneys of urine loaded with blood — the patient's health 



PAROXYSMAL HEMATURIA. 



765 



between successive attacks being apparently good, or at all events not 
seriously impaired. 

Causation Paroxysmal hematuria has hitherto been observed almost 

exclusively in males and in such as are of adult age. A few of the sufferers 
have previously had ague ; but with this exception the patients have, apart 
from their renal affection, enjoyed good health, and have been apparently 
I quite free from malarious taint. In all cases the onset of the disease is 
sudden, and almost without exception distinctly traceable to exposure to 
cold or draughts. 

Symptoms and progress. — The patient immediately after exposure or 
| even in the course of it, begins to complain of chilliness and uneasiness 
across the loins — the latter condition speedily passing into more or less 
severe aching, the former into an extreme sense of general cold, attended 
with pallor or duskiness of surface, shrinking of skin, and severe rigors ; 
together with which symptoms there may be weakness, stiffness or aching 
in the limbs, yawning, nausea and vomiting, and retraction of the testicles. 
During this time the temperature is lowered, and often by as much as two 
or three degrees. After the patient has been in this condition for half an 
hour, or it may be an hour or two, he is astonished to find on passing 
water that this fluid is exceedingly dark-colored and turbid, not unfre- 
quently resembling porter. The general symptoms now speedily abate, 
and the patient, after a little reactionary rise of temperature, but no sweat- 
ing stage, appears at the end of a few hours to be perfectly well. The 
urine gradually loses its specific characters, and a little later perhaps than 
the patient's apparent restoration to health resumes its normal condition. 
The porter-like urine, which is generally faintly acid and of variable 
density, deposits an abundant grumous sediment, and contains a large 
quantity of albumen, together with granular and hyaline casts and prob- 
ably crystals of oxalate of lime, but in place of blood-corpuscles (which are 
detected rarely and in small numbers) presents abundant brownish granu- 
lar matter, which is supposed to be due to the disintegration of these 
bodies. [Hence the disease is more properly called hsematinuria.] The 
onset of subsequent attacks is equally sudden with that of the first ; and 
the succession of events is repeated exactly in them. Moreover, the later 
attacks, like the first, are generally distinctly traceable to the influence of 
cold: the slightest draught or the slightest chill being in many cases com- 
petent to evoke them. In some instances the paroxysms recur with almost 
ague-like periodicity : more generally, however, they come on at irregular 
intervals. Sometimes patients suffer from them once or twice a day, some- 
times once or twice a week, sometimes at longer intervals, and they often 
lose their liability to them during warm weather. With such variations 
the disease may last for years, generally too without inducing any serious 
consequences as respects either the condition of the kidneys or the general 
health. The patient, however, often becomes anaemic, languid, and weak. 

Pathology — The pathology of paroxysmal hematuria is somewhat ob- 
scure. It has been supposed to have some relation with ague, with oxaluria. 
and with rheumatism. It has been regarded, on the one hand, as an affec- 
tion of the kidney, on the other as a disease of the blood. But whatever 
view be ultimately adopted, there are certain facts which stand out clearly : 
namely, first, the dependence of the paroxysm on a cutaneous chill; second, 
the intense congestion of the kidney which attends the paroxysm ; third, 
the relief of both congestion and paroxysm by a copious discharge of blood; 
and fourth, the independence of all these conditions of any structural dis- 



766 



DISEASES OF THE GENITO-URTN ARY ORGANS. 



ease of the kidney. The phenomena of the disease, indeed, are probably 
due to an influence transmitted from the skin to the vaso-motor nerves of 
the kidney, in virtue of which temporary congestion takes place. 

[The American student must be careful not to confound this disease 
with one of the many results of malarial poisoning occasionally met with 
in portions of the Southern States, and characterized by jaundice, great 
irritability of the stomach, giving rise to uncontrollable vomiting, and a 
peculiar alteration in the color of the urine, generally attributed by Southern 
physicians to the presence of blood. M. Berenger Feraud, who has studied 
the disease in Senegambia, has arrived at a different conclusion, holding 
that the foreign body to which the urine really owes its remarkable appear- 
ance is bile, having been able to find blood- corpuscles or hsematin in only 
a very small proportion of the cases. He therefore prefers to call it me- 
lanuric bilious fever of warm climates. It generally yields to anti-periodic 
doses of quinia — a remedy which has no power to prevent the attacks in 
paroxysmal hsematuria.] 

Treatment Many remedies have been employed, but none with any 

striking success: quinine and arsenic on the ground of the periodicity 
Which the disease presents; iron because of the patient's anasmic state ; 
perchloride of iron, gallic acid, and lead for their styptic properties; and 
digitalis and ergot of rye on account of their influence in contracting the 
arterioles. The most important treatment, however, is the prophylactic : — 
during the paroxysm the patient should be placed in a bed and kept warm ; 
and at other times he should be cased in flannel and otherwise warmly 
clad, his feet and loins especially should be protected, and he should care- 
fully avoid all exposure to draughts, all loitering in the cold, and riding in 
cold weather in an open vehicle. 



XVIII. DIABETES. {Diabetes Mettitus. Glycosuria.) , 

i 

Definition. — The most striking phenomenon of this disease is the ex- 
cretion of urine containing a greater or less amount of glucose or grape- 
sugar. It is not, however, every one whose urine contains glucose who can 
be said to suffer from diabetes. For it has been shown that this substance 
may be present in the urine temporarily or in small quantities in many 
affections involving hepatic congestion, such as injuries or organic lesions 
of the liver, and obstructive cardiac and pulmonary complaints, in certain 
affections of the central nervous organs, and also under the influence of 
particular articles of diet ; while none of the other special phenomena of 
diabetes are either present or tend to become developed. 

Causation. — The cause of diabetes is not known. It is certainly heredi- 
tary in some cases ; it occurs at all ages, from infancy to old age, and in 
both sexes, though about twice as frequently in the male as in the female. 
It has been attributed to exposure, to habits of life, to injuries of various 
kinds, and to mental disturbance. In most cases, however, no cause what- 
ever can be assigned or suggested. 

Symptoms and progress Diabetes, for the most part, comes on insidi- 
ously. The patient perhaps observes, almost by accident, that day by day 
his urine is getting more and more abundant, his thirst is increasing, his 
appetite is getting voracious, and yet that he is losing flesh and strength. 



DIABETES. 



767 



Occasionally it happens that he is also, and possibly first, struck by some 
peculiarities in his urine dependent on the presence of sugar in it. He 
finds that when drops of it fall upon his trousers or boots, a whitish pow- 
dery film is left after evaporation, or that flies, bees, or other insects are 
attracted to the contents of his chamber-pot, or to surfaces on or against 
which he has emptied his bladder. The prominent features of the disease 
are comprised in this brief sketch : they are, the excretion of an excessive 
quantity of urine loaded with glucose, intense thirst, voracious appetite, 
together with progressive emaciation and debility, followed after a longer 
or shorter time by death. These symptoms, however, present a good deal 
of variety, and many others of more or less importance are generally as- 
sociated with them. We will discuss them seriatim. 

The quantity of urine discharged is generally much larger than natural; 
so that the patient not only micturates frequently during the day, but is 
compelled to rise from his bed several times in the night in order to relieve 
himself. Its quantity depends, of course, mainly upon the quantity of 
fluid which he drinks, and therefore varies largely. It is sometimes little 
more than normal, but generally averages between six and twelve pints 
daily, and occasionally rises to twenty, thirty, or more. The urine is 
usually of a pale yellow color, acid, clear and free from sediment, and has 
a peculiar odor which has been likened to that of new milk, apples, or hay. 
Its specific gravity, notwithstanding the large quantity passed, is always 
abnormally high. It is rarely below 1035, often rises to 1045 or 1050, 
occasionally reaches 1060, and is said to have exceeded 1070. The cause 
of this density is the presence of an abnormally large proportion of solid 
constituents. As a rule, considerably more urea is discharged daily by 
diabetic than by healthy persons ; but the amount of urea is usually very 
small in proportion to the quantity of fluid in which it is dissolved. The 
increase of specific gravity, therefore, is not due to that ingredient. It 
depends, indeed, almost entirely upon sugar. This varies of course con- 
siderably in quantity ; but it generally forms from eight to twelve per cent, 
of the urine, and ranges from fifteen to twenty-five ounces daily. Its 
amount may, however, be much less than this, and also much greater. It 
is greatest after meals, and is always largely increased after the ingestion 
of sugar or starchy food. Under opposite circumstances it diminishes ; 
and it may disappear absolutely if the diet be restricted to nitrogenous 
substances. Sometimes, under the influence of inflammatory affections, 
and again towards the close of the disease, the urine diminishes both in 
quantity and in specific gravity, and its sugar lessens or fails ; sometimes 
it becomes albuminous, and hyaline casts may be found in it. Dependent 
in some degree on the irritant effects of the urine, the urethral orifice in 
the male, or the vulva in the female, becomes red and irritable, and even 
excoriated or eczematous. The sexual appetite is sometimes augmented 
in the beginning ; but both that and virile power diminish before long, and 
then disappear. 

One of the most distressing symptoms of which diabetic patients com- 
plain is extreme thirst; and it is one of the first symptoms to make its 
appearance. The appetite, too, is generally excessive, sometimes ravenous. 
This, however, is subject to considerable variation. Sometimes it is no 
greater than natural, sometimes it is much impaired ; and there may even 
be nausea and absolute loathing of food. The latter conditions often come 
on towards the termination of the case. The mouth, fauces, and tongue 
are usually dry, clammy, and morbidly red. The gums are apt to retreat 



768 



DISEASES OF THE GENI TO- URI N ARY ORGANS. 



from the teeth, and these latter to become loose and fall out. The patient 
often complains of uneasiness or sinking at the epigastrium. The bowels 
usually are constipated, the motions scanty and dry ; but occasionally, and 
not unfrequently ushering in the fatal event, dysenteric diarrhoea super- 
venes. 

The skin of diabetic patients is almost always dry and harsh, though 
occasionally slight perspirations occur, and some patients perspire freely. 
There is often a tendency to itching ; and various eruptions, especially 
eczema, psoriasis, and boils, are said to be of common occurrence. The 
hair sometimes falls out. The skin, or rather perhaps the patient gene- 
rally, yields an unpleasant odor, like that characteristic of his urine. 

The symptoms referable to the heart and lungs are merely such as usu- 
ally attend wasting disease, namely, increasing feebleness and rapidity of 
pulse, and more or less shortness of breath, especially on exertion. The 
blood of diabetic patients contains glucose, of which as much as '3 to *5 
per cent, has been detected by analysis. 

Nervous phenomena of various kinds usually manifest themselves in the 
course of the disease. The patient becomes apathetic, morose, or taciturn, 
or irritable, or towards the close drowsy or comatose. Insanity sometimes 
supervenes ; and occasionally various forms of hyperesthesia, loss of motor 
power, and the like. Impairment of vision is also a common incident of 
the disease; in some cases the patient loses simply the power of adjust- 
ment for near vision — he becomes prematurely presbyopic ; in some he 
suffers from amblyopia ; while in some soft cataract forms in one or both 
eyes. 

But, besides the above phenomena, others come on which are not so 
much referable to any one organ as to general impairment of nutrition and 
advancing debility. There is great susceptibility to external cold. A sort 
of hectic condition arises, occasionally attended with febrile elevation of 
temperature ; generally, however, the temperature remains normal or falls 
a little below the normal. Emaciation is almost constant ; the fat disap- 
pears, the muscles shrink, the frame becomes attenuated, the skin appears 
tightly drawn over the forehead and other parts of the face, and is thrown 
into fine wrinkles when expressional and other movements of the facial 
muscles are executed. Occasionally, on the other hand, and more particu- 
larly in elderly persons, the tissues remain overloaded with fat to the end. 
Towards the close of the disease anasarca, generally limited to the lower 
extremities, is of common occurrence. And not unfrequently gangrene 
takes place in the fingers, toes, or more extensive portions of the extremi- 
ties, in the genitals, nose, ears, or other parts. 

Another complication which is at least as common as any of the above, 
and on the whole of far more importance, is pulmonary phthisis. This 
attacks a large proportion of diabetic patients ; and indeed of patients who 
die of diabetes probably one-half suffer from it. The affection is rarely if 
ever in the form of miliary tuberculosis, but almost invariably in that of 
caseous consolidation, with tendency to disintegration and the formation of 
cavities. 

In some cases the progress of diabetes is exceedingly acute and rapid. 
Death has resulted from it after an illness of two or three weeks only. On 
the other hand, death may be delayed for ten years or more. For the most 
part, however, the patient succumbs in from one to three years. Recovery 
is exceedingly rare. The cause of death usually is asthenia, hastened in 
some cases by gangrene, dysentery, or phthisis ; but not unfrequently the 



DIABETES. 



769 



patient dies comatose. „ Diabetic patients bear fatigue, mental or bodily, 
very badly, and at an advanced period of their disease are apt, after such 
fatigue, to fall into a state of almost sudden collapse, from which they do 
not rally. 

The above remarks apply to the usual form of the disease. It must be 
added, however, that in elderly persons and especially in such as are gouty, 
the urine not unfrequently contains sugar, it may be in large quantities, 
and yet few or none of the other symptoms of diabetes are present. The 
! glycosuria under such circumstances may persist for years, either uniformly 
or with remissions, the patient perhaps passing at times more water than 
natural, and suffering more or less from dyspepsia, yet presenting no ema- 
ciation and no serious impairment of strength, and ultimately recovering, 
or dying, not of diabetes or its ordinary complications, but of some inde- 
pendent disease. 

Morbid anatomy and pathology. — Morbid anatomy reveals little as to 
the nature and processes of diabetes. Excluding dysenteric affection of 
! the bowels, gangrene of various parts, pulmonary tuberculosis, and cataract 
(which are not present in all cases, and present no distinctive characters), 
but little remains for description. The kidneys generally are enlarged and 
I more or less congested, and the epithelial lining of the tubules is occa- 
; sionally in a distinctly fatty condition. The liver and other chylo-poietic 
viscera, to which on theoretical grounds attention should be mainly di- 
rected, present no constant lesions. The former has occasionally been 
found cirrhotic, the latter inflamed ; but far more commonly all appear 
healthy. The nervous system, again, has been examined with care, on 
account of the influence which certain parts of it have in causing glyco- 
suria. Tubercular and other tumors have occasionally been discovered in 
the neighborhood of the fourth ventricle ; and Dr. Dickinson has recently 
drawn attention to the existence of small cavities, sometimes visible to the 
naked eye, originating in softening and degeneration of the tissues around 
some of the smaller arteries, and containing, when fully formed, simply 
serous contents. He has found them in most parts of the central nervous 
organs, but more particularly in the olivary bodies, the median plane of 
the medulla oblongata, and the gray matter in the floor of the fourth ven- 
tricle. 

If the pathology of diabetes has not been completely elucidated, it has 
at any rate had much light thrown upon it during the last few years by the 
labors of Bernard and other investigators. It has been proved that the 
liver, besides manufacturing bile, is an organ for the conversion of albumi- 
nous and starchy matters (mainly if not entirely those obtained directly 
from food) into dextrine or glycogen — a starchy substance which exists in 
large quantities in the liver, and is readily convertible by ferments (and 
among others by a peculiar albuminous ferment existing in the blood but 
not yet separated from it) into glucose, or grape-sugar. It is probable that 
the healthy liver also converts sugar itself into glycogen, and that hence, 
amongst other duties, the liver opposes a barrier to the admixture of sac- 
charine ingesta with the blood. What becomes of this glycogen, which is 
formed and accumulates in the liver, we need not stop to consider. It is 
certain, however, that in health neither it nor glucose is discovered in the 
blood. Further, experiments made by Bernard, Schiff, and others have 
demonstrated the important influence which the nervous system exerts over 
the glycogenic function of the liver. It has been proved that by irritating 
various parts of the central nervous organs artificial diabetes may be in- 
49 



770 



DISEASES OF THE GENI TO - URINARY ORGANS. 



I 



duced — irritation of the floor of the fourth ventricle, particularly of a spot 
in it midway between the origins of the auditory nerves and par vagum, 
being especially efficacious in this respect. There is reason to believe that 
this spot is either the origin of, or in relation with, the tracts of sympa- 
thetic nerves which regulate the diameter of the hepatic vessels ; and that 
through the agency of these nerves the vessels of the liver become actively 
dilated, upon which phenomenon congestion and glycosuria supervene. 
SchifF, by dividing the anterior columns of the cervical cord through which 
the sympathetic tracts above referred to pass on their way to the liver, 
also produces glycosuria ; which, again, is probably dependent on dilatation 
of the hepatic vessels and hyperemia, but dependent upon dilatation of 
paralytic origin, and which, like the diabetes it causes, is of comparatively 
long duration. Experiment would therefore seem to show : that diabetes 
depends on dilatation of the hepatic vessels, with accumulation of blood in 
them, and rapid flow of blood through them, and consequently on increased 
or rather modified functional activity of the liver; and that this dilatation 
may be either active — the result of irritation of nerves — producing for the 
most part a temporary condition of diabetes, or passive — the result of 
paralytic dilatation — inducing as a rule a chronic form of glycosuria. The 
dependence of diabetes on hyperemia of the liver has been demonstrated 
by other experiments in wdiich hyperemia has been brought about without 
the intervention of the nervous system ; and is confirmed by the not un- 
frequent occurrence of some degree of the affection in pathological conges- 
tion of the liver arising from cardiac or pulmonary disease, from injuries 
to the liver, and from inflammation of the organ. According to these 
views, which, it may be remarked, only partially explain the dependence 
of diabetes on hepatic derangement, the occasional and temporary impreg- 
nation of the urine with sugar would seem to have an irritative, the typical 
forms of diabetes a paralytic, origin. 

Treatment. — The treatment of diabetes is a subject of great interest, and 
has been regarded and conducted from all points of view with varying 
degrees of success. As with most other diseases, some cases of it are so 
serious from the beginning and so rapidly fatal that all efforts to arrest 
their progress are futile ; while some cases are so slightly pronounced that 
the patients either remain in fair health in spite of their sugary urine, or 
appear to derive benefit from almost any treatment. Between these ex- 
tremes lie the great majority of cases, which, if not admitting of cure, 
undoubtedly often admit of important alleviation by appropriate treatment. 
It may at once be stated that the use of blisters and other local applications 
to the head or to the liver has been advocated and practised by various 
physicians, on the ground that one or other of these organs was at fault ; 
and beneficial results have been recorded. Further, we may at once point 
out the general importance of promoting the functions of the skin by warm 
baths and warm clothing ; of maintaining the regular action of the bow T els; 
of alleviating, arresting, or curing dysentery and the other complications 
wiiich so frequently attend the progress of diabetes; of preventing all 
unnecessary fatigue ; and of putting the patient under those external con- 
ditions which are commonly regarded as conducive to health. 

The most important point, perhaps, in the treatment of diabetes is the 
regulation of the patient's diet. It has long been proved that the absten- 
tion from sugar and from those other articles of food which are most readily 
convertible into sugar is always attended with a marked diminution in the 
quantity of sugar voided, in the specific gravity of the urine, and in the 



DTABETES. 



771 



amount of that fluid secreted; and that in a very large proportion of 
diabetic patients there is at the same time gain of flesh with manifest 
improvement of health. For these reasons it is customary to debar the 
patient from certain alimentary matters, especially sugar in every form, 
and all vegetables or vegetable products whose nutritious qualities depend 
on sugar, starch, or related matters — among which may be enumerated 
bread, potatoes, rice, sago, tapioca, peas, beans, turnips, parsnips, carrots, 
and most fruits. There is good reason also to believe that alcohol in all 
its forms is pernicious. Among permissible foods are : first, green vege- 
tables ; second, all sorts of animal food, including milk, eggs, cheese, and 
butter ; and, third, tea and coffee without sugar. It is found, however, 
in practice almost impossible to overcome the craving for bread or some 
equivalent for bread which soon arises under the use of a restricted diet. 
Various substitutes have been suggested and may be used temporarily; the 
most important being gluten bread, bran cake, and almond biscuits or 
rusks, to which may be added (as being more palatable, though more ob- 
jectionable) toast uniformly and deeply browned. Lately Dr. Donkin has 
advocated the administration of skim milk, to the exclusion of all other 
food. He gives from six to eight pints daily to an adult. And it is cer- 
tain that many patients in a short time get fairly reconciled to it, that they 
often gain strength and flesh under its use, and that at the same time 
the urine diminishes in quantity, in density, and in the amount of sugar it 
contains. 

It has often been held important to restrain the patient from gratifying 
his intense craving for drink. It is cruel, however, to put such restraint 
upon him, and of very doubtful benefit. Acidulated drinks are said to be 
specially useful in assuaging his thirst, and, above all, dilute solutions of 
phosphoric acid. 

Of all drugs, opium seems to be the most efficacious. It has long been 
esteemed in the treatment of diabetes ; and especially Dr. Pavy has latterly 
extolled its virtues. Diabetic patients are said to be little susceptible of 
the influence of opium, and may therefore take it with safety in compara- 
tively large quantities. It is best, however, to commence with small doses, 
say half a grain, of the powder, three times a day, and gradually to aug- 
ment them, according to their effect, until each dose is increased to five or 
six grains. A fair number of cases have been recorded in which great 
amelioration, if not absolute cure, has followed this treatment. Still more 
recently Dr. Pavy has employed, and apparently with considerable success,, 
codeia, in doses commencing at about half a grain, three times a day, and 
gradually increasing to two or three grains. 

Again, alkalies — bicarbonates, acetates, citrates — have been regarded as 
valuable remedies ; as also has the hot-vapor bath. Iron and other tonics 
are sometimes beneficial. [Other remedies which have been employed with 
more or less success are lactic acid, rennet, and yeast.] 

As respects the treatment of the masked diabetes of elderly people, it 
is impossible to lay down definite rules. It is generally needless to carry 
out the plans recommended above, at any rate, to carry them out strictly 
or continuously. 



772 



DISEASES OF THE GENITO-URI NARY ORGANS. 



XIX. DIABETES INSIPIDUS. (Diuresis.) 

Definition. — Under these titles are grouped a number of cases, which 
are linked together and characterized by the association of extreme thirst 
with the excretion of a large quantity of pale limpid urine, free from sugar, 
and of low specific gravity. 

Causation — Diabetes insipidus is rare, but appears to occur at any age, 
and in either sex. The causes to which it has been attributed are various. 
Among them may be mentioned tuberculosis, diseases of the brain, drink, 
accident, and exposure. According to Trousseau and some others, it has 
a close relation to diabetes mellitus, not only in symptoms, but in the facts 
that there is an hereditary connection between them, and that the former 
is occasionally a sequela of the latter. Bernard, moreover, has shown that 
diabetes insipidus, as well as glycosuria, may be produced by irritation of 
the floor of the fourth ventricle. 

Symptoms and progress — This affection sometimes comes on insidiously, 
sometimes quite suddenly. Its chief symptoms are the following : First, 
the secretion of large quantities of urine ; the quantity passed is often con- 
siderably larger than in saccharine diabetes ; it maybe as much as 20, 30, 
or 40 pints daily, or even twice as much ; the urine, moreover, is pale, 
watery, of low specific gravity (often not above 1002, 1003, or 1004), and 
containing no sugar or other abnormal ingredient. Second, extreme thirst ; 
this is proportionate to the diuresis, the quantity of fluid drunk being equal 
or nearly so, to the quantity eliminated. 

Other symptoms vary. In some cases the patient appears to be well in 
all other respects, and, except for the continued presence of his infirmity, 
enjoys life, probably attaining old age. In some cases, he presents all the 
usual indications of diabetes mellitus ; he has a voracious appetite, a parched 
mouth, and dry skin ; he becomes anaemic, sallow, emaciated, and weak ; 
and, after a longer or shorter time, dies as ordinary diabetics die. In other 
cases, again, diabetes insipidus is, from its commencement, associated with 
the presence of tuberculosis or other lesions, and is thus a mere incident or 
complication of a more serious malady. 

Morbid anatomy In a few cases, which have been collected by Dr. 

W. Roberts, the morbid anatomy of diabetes insipidus is illustrated. 
There is little, however, in the recorded post-mortem examinations to 
throw light on the nature of the affection. In several of the cases, the 
kidneys were atrophied, and in one hydro-nephrotic. There is some reason 
to suspect that in these the primary affection was renal. In others, the 
kidneys were healthy, as also were they in a case which died under our 
own care. In this case, as in one of Dr. Roberts's, the patient suffered 
from tuberculosis, which probably caused death. Here, undoubtedly, the 
diuresis was symptomatic only. 

Treatment. — There is little to say about the treatment of diabetes in- 
sipidus. Various remedies, including tonics and regulation of diet, have 
been tried. Trousseau and Rayer strongly recommend valerian in large 
doses. The former commences with two or three drachms of the extract 
daily, and generally pushes the treatment until the daily portion reaches 
an ounce. Baths are sometimes beneficial. The constant galvanic current 
passed between the loins and epigastrium, has recently been tried by Dr. 
M. Seidel. [Cases are reported in which recovery followed the long-con- 
tinued use of the extract of ergot and tannic acid, given in large doses. 
In one case, at least, a permanent cure was effected by ergot.] 



SUPPRESSION OF URINE. 



773 



XX. SUPPRESSION OF URINE. {Ischuria Renalis.) 

A. Functional suppression of urine. 

More or less complete suppression of the urinary secretion, lasting for 
a longer or shorter period, is not unfrequent in the course of many differ- 
ent diseases or morbid conditions, among which may be especially enume- 
rated malignant cholera, certain of the infectious fevers, acute enteritis, 
inflammatory affections of the kidneys, collapse, and hysteria. In many 
such cases the suppression is symptomatic only, and probably scarcely 
affects the patient injuriously ; in others, the retention of urea and other 
effete nitrogenous matters in the blood which attends the suppression in- 
duces or aggravates typhoid phenomena and thus hastens death. It is 
remarkable, however, how sometimes, and more especially in cases of hys- 
teria, the urine continues for many weeks at a time in almost complete 
abeyance — the patient going, perhaps, for two or three days at a time with- 
out secreting any, and then, perhaps, passing only an ounce or two in the 
course of the twenty-four hours — and yet the patient remains wholly free 
from evidence of urasmic poisoning. These several cases of suppression 
are considered elsewhere in connection with the diseases in which they 
occur, and need not further detain us now. For the treatment of these 
cases, simple diuretics, more especially copious bland fluids, the use of hot 
hip or other baths, and the application of counter-irritants to the lumbar 
region, comprise everything likely to be of real service. 

B. Suppression o f urine f rom obstruction. 

Causation and morbid anatomy Another class of cases of so-called 

' suppression' is that in which the failure to discharge urine depends on 
the existence of some mechanical obstacle to the escape of urine, situated 
either in the pelvis of the kidney or, as is far more common, in some part 
of the ureter. The permanent obstruction of one ureter, its fellow remain- 
ing pervious, is, as we have already shown, a not uncommon accident ; 
and on the one hand results in the production of hydro-nephrosis with 
ultimate wasting of the corresponding kidney, and on the other hand leads 
to increased functional activity of the opposite organ, which henceforth 
does the work of both. Obstruction of the ureter is most commonly due 
to the impaction of a calculus ; and hence it is not altogether remarkable 
that a person who has had one ureter blocked up and one kidney destroyed 
should be liable to the occurrence at some future time of the same accident 
on the opposite side. And indeed it is generally in cases of this sort that 
mechanical suppression occurs. 

Symptoms and progress. — The suppression of urine under these circum- 
stances comes on suddenly. Sometimes it is, and remains, absolute ; per- 
haps more frequently a small quantity of urine of low specific gravity, and 
containing little urea, is still passed at irregular and probably long inter- 
vals. It is very remarkable that in most cases of this kind, no matter 
how complete the suppression may be, the patient scarcely seems to suffer 
during the first seven or eight days. He may perhaps have a little nausea, 
there may be some degree of insomnia, and there may also be some failure 
of muscular strength ; and this is all. At the end of this time, however, 
manifest symptoms of the effects of the retained poisonous matters on the 



774 



DISEASES OF THE GENITO- URINARY ORGANS. 



system arise. They consist in the first instance in muscular tremors asso- 
ciated with distinct increase of muscular debility ; and in the next place 
in slow, panting respiration, and contraction of the pupils. These phe- 
nomena appear never to be absent, and they become more and more 
marked with the progress of the case. But soon other symptoms are. 
superadded. The patient complains of anorexia and thirst with dryness 
of the mouth and fauces ; he becomes drowsy, but sleeps only in snatches ; 
and he may present a little occasional delirium. Death, which is rarely 
preceded by coma, and still more rarely by convulsions, takes place mainly 
by asthenia at the end of two or three days from the first occurrence of 
toxsemic symptoms. Throughout the patient's illness there is no fever ; 
on the contrary, towards the close the temperature tends to fall ; the pulse 
differs little in frequency from the normal, and the skin is often moist. 
The symptoms indeed are widely different from those which are ordinarily 
attributed to uraemia. 

The diagnosis of cases of this kind is often facilitated by the combina- 
tion of a history of some long antecedent attack of renal colic on one side, 
with present symptoms of an acute attack of the same kind on the oppo- 
site side. The calculus soon, however, becomes impacted, and then prob- 
ably all local pain and uneasiness disappear. Further, there is no neces- 
sary pain or uneasiness in the loin. 

Treatment For this affection we can do little or nothing. We may 

adopt such treatment as is recommended for renal colic in the hope that 
the stone, if there be one, may be aided in reaching the bladder ; and we 
may endeavor, as Dr. W. Roberts recommends, by kneading the abdomen, 
to empty the distended ureter and coincidently it may be to dislodge the 
calculus. 



Section II. — DISEASES OF THE PELVIC ORGANS. 

The diseases of the genito-urinary organs, situated within the pelvis, 
are of extreme interest and importance ; but they are claimed for so many 
departments of practice that it is difficult to determine to what extent they 
ought to be included in a work on medicine. We propose to discuss very 
briefly, and mainly in reference to diagnosis, those among them which are 
important on account of their liability to be confounded with, or to com- 
plicate, the diseases, already considered, of the other abdominal viscera. 



I. DISEASES OF THE URINARY BLADDER. 

1. Inflammation arises under many different circumstances, which need 
not be enumerated. It is characterized anatomically by congestion and 
thickening of the mucous membrane, with the secretion of mucus, which 
may be simply abundant or may acquire the characters of pus. Some- 
times submucous extravasations of blood occur, sometimes blood escapes 
from the surface. Occasionally ulceration takes place, or membranous 
pellicles form, or the mucous membrane itself or large patches of it exfoli- 



DISEASES OF THE URINARY BLADDER. 



775 



ate and are discharged. Occasionally, also, abscesses are developed in the 
substance of the vesical walls, or inflammation commencing at the mucous 
surface extends in depth until it involves the serous membrane. 

The symptoms of inflammation of the bladder are mainly : pain and 
tenderness in the neighborhood of the organ, therefore in the perineum 
and immediately above the pubes, extending probably to the penis, to the 
sacrum or loins, and to the contiguous parts of the thighs; irritability of 
bladder, with constant desire to pass water ; and the discharge of urine 
which, according to circumstances, presents only a slight cloud mucus, or 
more or less abundant thick ropy mucus, or mucus mingled with blood, or 
pus. Sometimes the urine contains shreds of tissue, and frequently be- 
comes alkaline and offensive. Cystitis may be acute or chronic, and 
varies greatly in its intensity and danger in different cases. When acute 
the general febrile symptoms may be very severe. Cystitis often leads to 
pyelitis ; and further, the latter affection not only resembles cystitis in 
some of its symptoms, but inflammation, commencing in the pelvis of the 
kidney, is apt to travel along the ureter and thus to involve the bladder. 

For the treatment of cystitis we must refer to surgical works and to 
what has been previously said in reference to pyelitis. 

2. Tubercle affects the bladder but rarely, and is then almost invariably 
associated with tubercle of the kidneys and ureters, or (which is yet more 
common) with tubercle of the prostate and vesicuke seminales. It is of 
the miliary variety, and tends, as in the intestines and on other mucous 
surfaces, to produce shallow circular ulcers, which, by coalescence, are apt 
to cause superficial destruction of some extent. 

The symptoms are in themselves undistinguishable from those of chronic 
cystitis. 

3. Morbid growths The most important of these are villous tumors 

and the several forms of malignant disease. The latter usually commence 
in the prostate or some neighboring part, and are rarely of primary origin 
in the bladder. Tumors are generally attended with more or less pain, 
referable to the bladder, and more or less interference with micturition. 
Moreover they are apt to be complicated, after a while, with symptoms of 
cystitis. Villous and malignant tumors are frequent sources of profuse 
hemorrhage. The latter are further characterized by sooner or later in- 
volving contiguous organs, and by inducing progressive cachexia. 

4. Dilatation. — This condition depends on the accumulation of urine or 
other matters within the cavity of the bladder. It may occur in paraple- 
gia and other paralytic conditions from paralysis of the vesical walls, and 
also in hysteria. It is common in the later stages of many of the specific 
fevers, and during the typhoid condition, from failure of the reflex influ- 
ence on which the evacuation of the bladder depends; and it is especially 
common as a consequence of obstructive disease, such as stricture of the 
urethra, enlarged prostate, or tumors of any kind involving or compressing 
the neck of the bladder. When the dilatation is chronic, and secondary 
to some impediment, the muscular walls become hypertrophied, and sac- 
culi are developed. Under any circumstances the mucous surface is apt 
after a time to get inflamed; and the dilatation and inflammation are both 
of them liable, sooner or later, to involve the ureters and the cavities of 
the kidneys. 

Symptoms. — In cases in which retention of urine is dependent on 
paralysis, or connected with the presence of febrile disturbance or the 
typhoid condition, the bladder may become enormously distended without 



776 DISEASES OF THE GrENITO - URINARY ORGANS. 



causing any apparent suffering to the patient. Even in cases of chronic 
stricture and such-like conditions in which, although the dilatation of the 
bladder may be extreme, it has been slowly attained, the organ becomes 
remarkably tolerant of its burden, and the patient suffers comparatively 
little. In other cases his sufferings are often extreme. He complains of 
more or less general uneasiness, pain and tenderness over the hypogastric 
region, in the penis and in adjoining parts ; but the pain is subject to fre- 
quent exacerbations, dependent on the violent but futile spasmodic efforts 
of the bladder to void its contents. In many cases, if the obstruction be 
not complete, more or less urine either constantly dribbles away or is 
passed in small quantities during the spasmodic efforts. The distended 
bladder forms a tense, ovoid tumor, which rises out of the pelvis from 
behind the pubes, and may extend upwards to the umbilicus or beyond. 
It occupies the middle part of the abdomen, and, unless it be largely sac- 
culated, is symmetrical in form and position. The enlarged bladder can 
rarely fail of recognition if due attention be paid to the position and form 
of the tumor, to the perfect dulness on percussion which it presents, and 
to the characteristic pain which so often attends it and is evoked by ma- 
nipulation. 

Treatment. — When the bladder becomes distended in the course of 
fever and paralytic affections, equally as when it becomes distended in 
consequence of surgical diseases, the urine should be drawn off; and, if 
necessary, should be drawn off periodically. Further, if the urine be 
ammoniacal, or there be discharge of ropy mucus or pus, it may be well 
not only to empty the bladder, but to wash it out either with pure water 
or with dilute antiseptic solutions. 



II. DISEASES OF THE UTERUS, FALLOPIAN TUBES, AND 

OVARIES. 

A. Metritis and Oophoritis. 

Causation and morbid anatomy Inflammation of the parts above 

named may result from many causes, but is most apt to occur during the 
menstrual period and after parturition. Inflammation may affect the mu- 
cous surface only of the uterus, or this together with the muscular coat ; 
and in the latter case is apt to spread to the surrounding connective tissue 
and to the peritoneum; the Fallopian tubes are frequently involved. The 
inflamed mucous membrane gets congested, thickened, and pulpy, and 
occasionally (especially in the puerperal variety) is thrown off as a slough. 
The surface may at first be dry, but soon secretes a thin fluid, and subse- 
quently pus, with which blood may be mingled. When the muscular 
parietes are involved, they become soft, tumid, infiltrated with inflamma- 
tory products, and occasionally studded with spots of extravasation. Some- 
times abscesses form. Inflammation of the ovary, which is said to be most 
common on the right side, is characterized by swelling, oedema, and con- 
gestion of the organ, and occasionally goes on to suppuration. Its peritoneal 
surface is often involved, and adhesions are then apt to form between it 
and neighboring parts. 

Symptoms — Metritis is generally a trivial ailment, attended with slight 



DISEASES OF THE UTERUS, ETC. 



777 



febrile symptoms ; but it is sometimes, and more especially in puerperal 
cases, a disease of extreme gravity, rapidly ending fatally with symptoms 
which bear a close resemblance to those of pysemia or severe erysipelas, 
with the former of which, indeed, it is apt to be complicated. The local 
indications of metritis are weight, pain, and tenderness in the situation of 
the womb. Pain and tenderness are felt in the hypogastric region, and 
occasionally manifest tumor may be recognized in that situation. Uneasi- 
ness, pain, and soreness are referred to the sacrum or lower lumbar region, 
to the vulva and perineum, and to the groins and inner aspects of the 
thighs. Further, tenesmus and painful or difficult micturition are often 
complained of. When the ovary is inflamed, the pain and tenderness are 
referred to the region which the ovary normally occupies, namely, the 
point of intersection of the horizontal line drawn between the anterior 
superior spines of the ilia and the vertical line which divides the median 
from the lateral regions of the abdomen. The organ lies much higher 
than is generally supposed, and is deeply situated. When swollen it may 
often be distinctly felt in this situation. 

B. Morbid Growths. 

1. Tubercle occasionally affects the uterus and Fallopian tubes; it com- 
mences at the mucous surface and leads to the gradual destruction of the 
subjacent tissues, and to the abundant accumulation of cheesy matter. 
Much more rarely tubercle is discovered in the ovaries. Tubercle of these 
organs is almost invariably associated with advanced tuberculosis of other 
parts, more especially of the peritoneum. 

The symptoms, if any special to these organs be complained of, are those 
of subacute inflammation. 

2. Myomata are common in the uterus. They probably never occur 
before puberty; and affect virgins, it is said, more frequently than married 
women. They originate in the substance of the uterine walls ; if near the 
inner surface tending to form polypi, if near the outer aspect to form pe- 
dunculated outgrowths into the cavity of the peritoneum, if in the more 
central parts to remain imbedded. They vary in size from mere points up 
to masses of many pounds weight ; and may be single or multiple. They 
are usually slow of growth, not unfrequently become stationary, and are 
liable after a time to undergo degenerative changes and to shrink. Similar 
tumors are occasionally developed in the ovary. 

Symptoms — In addition to the special symptoms due to their weight, 
to their pressure on neighboring organs, such as the rectum and bladder, 
to their interference with parturition, and to their influence over the 
uterine functions, myomata frequently form masses which rise into the 
cavity of the abdomen, and may be recognized through the parietes as 
hard, rounded, or nodulated tumors. Such tumors necessarily vary in size, 
form, and position, and are generally more or less unsymmetrical. Inde- 
pendently of vaginal examination, their situation in the neighborhood of 
the uterus, their shape and density, their slow growth, the circumstances 
under which they have arisen, and the absence of involvement of lymphatic 
glands and remote organs, and generally of progressive cachexia, will 
usually enable an accurate diagnosis to be made. It must not be forgotten, 
however, that pedunculated tumors of this kind are apt to become attached 
to other parts, and, especially after pregnancy, to be left in comparatively 



778 



DISEASES OF THE GENITO- URINARY ORGANS. 



remote situations and thus to simulate renal or hepatic tumors, or tumors 
of other organs. 

3. Malignant disease is liable to affect all the organs under considera- 
tion. The uterus is a frequent seat of its primary development ; but this 
organ may also be affected secondarily. As a primary disease it usually 
commences between the ages of thirty-five and fifty ; and generally takes 
its origin in the cervix or os. Carcinoma is probably its most common 
form, but epithelioma and sarcoma are neither of them rare. The ovaries, 
also, are not very unfrequently the seat of cancerous or sarcomatous 
growths. These may be primary iii them or secondary to growths else- 
where. They are generally associated with similar disease in either the 
uterus, the peritoneum, or other abdominal organs. Ovarian malignant 
disease results for the most part in the development of lobulated masses, 
which in their general outlines are not unlike ovarian cystic tumors ; and, 
indeed, it is common for malignant disease of the ovaries to be associated 
with the more or less abundant development of cysts. 

The symptoms of malignant disease of the uterus need not detain us. 
And with respect to those of malignant disease of the ovaries, it may be 
observed that the tumors would probably in themselves be undistinguish- 
able from ordinary ovarian tumours, and that their recognition as being 
dependent on malignant disease must rest upon the progress of the case, 
the development of tumors elsewhere, the early appearance of cachexia, 
and the rapid downward tendency of the case. 

C. Cystic Tumors. 

Causation and morbid anatomy. — Cysts may arise either in the uterus, 
Fallopian tubes, or ovaries, or in connection with the peritoneal aspect of 
these organs. 

1. Dilatation of the uterus may be caused by accumulation of menstrual 
fluid, owing either to obstruction at the os uteri or to imperforate hymen 
or vagina. This is an affection of early life. At a later period, owing to 
obliteration of the os, or to its obstruction by tumors or other causes, the 
uterus may become distended by the glairy secretion of its mucous surface. 
Under the latter circumstances the uterus rarely attains a greater size than 
the fist ; under the former it may slowly acquire the bulk of the gravid 
organ, or even surpass it. The uterus may also be distended with blood. 

2. The Fallopian tube occasionally undergoes dilatation. This condi- 
tion is secondary to its closure or obstruction, generally at or near its junc- 
tion with the uterus. The affected tube becomes elongated, tortuous, and 
sacculated and increasingly dilated towards its fimbriated extremity. Here 
it occasionally measures three or four inches in diameter. 

3. Ovarian cysts. — But by far the most common and important cystic 
tumors are those which arise in the substance of the ovary. These may 
be simple or compound ; may vary in size from that of a marble up to a 
bulk far beyond that of the pregnant uterus ; and may form either a uni- 
formly rounded or ovoid mass, or an irregular lobulated tumor. They may 
be limited to one ovary, or, as not unfrequently happens, may affect both 
organs in unequal degrees. 

Cystic tumors of the ovary are rare before puberty. But from twenty 
or twenty-five upwards they are not unfrequent. They are most commonly 
met with between the ages of thirty and forty. The disease commences 
with the development of one or more small cysts in the substance of the 



DISEASES OF THE UTERUS, ETC. 



779 



ovary. These gradually increase in size ; and as they grow other cysts 
arise in relation with them, either in the ovary itself, or, if all manifest 
ovarian structure have disappeared, in the substance of the cyst-walls — a 
process which tends to go on indefinitely as well in the walls of the sec- 
ondary and all other later generations of cysts, as in those of the primary 
cysts. The result is the development of a more or less complicated cystic 
mass, the characters of which differ according to a variety of circum- 
stances. 

In some cases the secondary cysts tend largely to grow from the outer 
surface of the primary cysts, and hence the tumor soon acquires a marked 
lobulated character ; in some cases they appear mainly in the thickness of 
the party -walls between adjoining cysts, and the tumor becomes multilocu- 
lar, and presents a good deal of resemblance in its structure to an accumu- 
lation of air-bubbles in a viscid fluid ; in other cases the new growths are 
developed chiefly in connection with the inner surface of the cysts, and 
project or grow into their interior. The last mode of development pre- 
sents several varieties; in some instances papilke, villi or pedunculated 
cysts spring in groups from the lining membrane ; in some instances, and 
on the whole more frequently, these ifitra-cystic growths resemble those 
from which they spring, themselves give origin to others, and thus tend 
gradually to fill and even to distend the cavity which they occupy. 

The proportionate development of the constituent cysts presents great 
differences. In some instances one cyst becomes so large relatively to the 
others that the tumor becomes practically unilocular. In others the cysts 
are so numerous and small that the tumor appears to be nearly solid. And 
between these extremes all varieties may be met with. The enlargement 
of the tumors is due not solely to the formation of new cysts, but in great 
measure to the dilatation of the cavities already in existence. This is 
effected partly by the stretching of their parietes by their accumulating 
contents, and partly by the yielding of their parietes at points and the con- 
sequent coalescence of neighboring cysts — a process which may be readily 
observed in all its stages in most ovarian tumors. 

The contents of ovarian cysts differ largely. In many cases they are 
colorless ; but they are often yellow, brown, or green. They may be transpa- 
rent as water, or opaline, or perfectly opaque. They may be limpid, but are 
more usually glairy or viscid, and not unfrequently are thick, and glue- or 
jelly-like. When thick they often present a whitish or brownish sedi- 
ment. Chemically they contain modified albumen, and either mucus or 
colloid matter, and sometimes altered blood. Corpuscles of various kinds, 
more or less degenerated, are generally present : sometimes pus. Choles- 
terine is often observed. 

The walls of ovarian tumors vary greatly in thickness. Sometimes they 
are as thin as tissue-paper and perfectly pellucid. Much more frequently 
they are thick and tough, though varying in thickness in different parts. 
The outer parietes, like the party-walls between cysts, have in the progress 
of their growth a tendency to become attenuated and to give way at points. 
In thin-walled tumors free communications are occasionally thus estab- 
lished between the cysts and the abdominal cavity, which consequently 
becomes distended with their profuse secretion. And even in thick-walled 
cysts such communications, attended with more or less escape of contents, 
are not unfrequent. The walls of ovarian tumors consist mainly of con- 
nective tissue, in which are not unfrequently found microscopic cysts, to- 



780 DISEASES OF THE GE N IT 0- URINARY ORGANS. 

gether with patches or masses of cell-growth having some resemblance to 
sarcomatous or adenoid tissue. 

Among the various consequences of ovarian cystic tumors may be enu- 
merated: the occurrence of inflammation or suppuration; rupture of the 
cysts with the discharge of their contents into the peritoneal cavity ; the 
communication of suppurating cysts with the rectum, bladder, or other 
neighboring hollow viscera; the occurrence of peritonitis or ascites; and 
pressure on the bladder, rectum, ureters, or iliac veins, with the usual 
consequences of such pressure. 

Symptoms and progress The uterus dilated by fluid-contents takes 

the ordinary form, and occupies the usual situation, of the gravid organ ; 
and from these and other considerations the nature of the lesion can always 
be pretty readily ascertained. For the diagnosis of these cases, however, 
and of those of dropsy of the Fallopian tubes, we must refer to works upon 
the special diseases of women. 

Ovarian cystic tumors, in the early stage of their growth, either are un- 
attended with symptoms, or produce discomfort by sinking into the pelvis, 
and interfering by pressure with the functions of one or other of the neigh- 
boring pelvic organs. At this period they are probably detectable through 
the abdominal parietes, or by vaginal examination. With the progress of 
their enlargement they rise into the abdominal cavity, and ultimately in 
some cases produce enormous distension, displacing the abdominal viscera, 
and even by direct or indirect pressure on the diaphragm interfering with 
the respiratory functions. An ovarian tumor of moderate size can gene- 
rally be recognized as ovarian : by its obvious- connection with one or other 
of the iliac regions, whence probably it extends into the adjoining parts of 
the abdomen ; by its irregularity of form and the various degrees of resist- 
ance of its several lobules, with the probably distinct fluctuation of some ; 
by its dulness on percussion ; by its displacement of the intestines, and its 
mobility ; and by the absence of pain, tenderness, cachexia, and secondary 
growths. When it has attained a large size, all evidence of its commence- 
ment at one side of the abdomen has probably disappeared. But there is 
usually even then distinct evidence of its development from the lower part 
of the abdomen in the fact that the intestines are displaced upwards and 
laterally ; so that, in addition to tumor, there is complete dulness on per- 
cussion from the pubes upwards and outwards. [When examining the 
abdomen especially with the view of ascertaining the organ from which a 
tumor has taken its origin, the physician should not fail to note the exact 
situation of the navel. This in health occupies a position just midway be- 
tween the end of the ensiform cartilage and the pubes. In cases of ovarian 
or uterine tumors, the distance from the pubes to the navel will exceed 
that from the navel to the end of the ensiform cartilage, and the reverse 
of this will be true, if the starting-point of the morbid-growth is in the 
upper part of the abdominal cavity. Attention to this rule will often pre- 
vent the occurrence of errors of diagnosis.] The intestinal resonance can 
generally be distinguished in the flanks, and that due to the stomach, 
transverse colon, and perhaps some of the small intestines above. The 
tumor in this case also is probably irregular as to both form and resistance ; 
but it frequently happens, that one or two cysts preponderate largely over 
the others, and that distinct fluctuation may be felt in them. In some 
instances the bulk of the tumor consists of a single cyst ; and the tumor 
may then not only fluctuate distinctly but present a fairly uniform rounded 
shape. Pain, tenderness, and fever are not necessary accompaniments of 



DISEASES OF THE PELVIC 



PERITONEUM, 



ETC. 



781 



| ovarian tumors ; but these phenomena and others may arise during the 
1 progress of the disease. They depend on the supervention of one or more 
of those complications which have been previously enumerated : namely, 
inflammation in the cysts or in the peritoneum which surrounds them, the 
development of ascites, or pressure on the pelvic organs. When the tumor 
becomes very large, the patient's gait resembles that of a pregnant woman ; 
the legs get congested and anasarcous ; loss of appetite and perhaps vomit- 
ing supervene ; and the breath becomes short. Ultimately progressive 
emaciation and asthenia come on. 

Ovarian tumors are generally easy of diagnosis. They are apt some- 
j times to be confounded with uterine, hydatid, or other growths springing 
from the pelvis, and indeed cannot always be distinguished from them. 
I When of large size and mainly mono-cystic they may be mistaken for 
' ascitic accumulations. But the anterior position of the ovarian tumor ; 
the existence of resonance above and in the flanks, and of dulness over 
the whole of the tumor; the tendency for the abdomen to be thick rather 
! than wide, and to present some degree of irregularity of form ; and the 
total absence of any change in the level of the line separating the dull 
from the resonant regions when the patient shifts her position, are usually 
i sufficient to enable an accurate diagnosis to be made. It must not be for- 
! gotten, however, that ascites is apt to come on in the course of ovarian 
dropsy, and that hence the two conditions are not unfrequently associated. 

Treatment The treatment of ovarian cystic tumors alone calls for 

remark here. And even in reference to this subject we have little to say. 
Drugs have no influence direct or indirect over them. Of course if in- 
flammation arise, the treatment usually adopted for peritonitis may be had 
recourse to ; if the patient be weak and emaciated, tonics and nutritious 
diet may be prescribed ; if she be suffering materially from the bulk of the 
tumor and its pressure on the stomach, diaphragm, or other organs, it may 
be tapped. But the only efficacious treatment is by the knife. The suc- 
cess of ovariotomy, or removal of the ovarian tumor by operation, has been 
so great of recent years, especially in the skilful hands of Mr. Spencer 
Wells, that all other forms of treatment have fallen into desuetude, excepting 
for those cases which from various circumstances are unsuitable for the 
radical cure. 



III. DISEASES OF THE PELVIC PERITONEUM AND 
CONNECTIVE TISSUE. 

We cannot conclude this section without directing attention to the re- 
markable tendency there is in the case of the pelvis, as there is also in that 
of the upper part of the chest, for diseases originating in one organ to im- 
plicate other organs in the vicinity, and for affections therefore originally 
distinct to cause almost identical ultimate results. 

Inflammations commencing in the ovary, uterus, or vagina, in the 
rectum, caecum, or bladder, in the serous membrane covering these 
organs, or in the connective tissue which invests them, or in connection 
with the bones or joints of the pelvis, are all apt to involve pelvic peri- 
tonitis with adhesions, infiltration and induration of the connective tissue 
of the pelvis, and the formation of abscesses which may burrow in various 
directions and open into the bladder, vagina, or rectum, or superficially in 



782 



DISEASES OE THE GENITO-URINARY ORGANS. 



the perineum, above the pubes, in the groin, or in the buttock. Further, 
as has before been pointed out, abscesses may gravitate from any of the 
parts situated in the abdomen or chest along the retro-peritoneal tissue, 
and thus induce the same consequences in the pelvis as though they had 
originated there. 

Similar remarks may be made in reference to the consequences of tuber- 
cular disease of the uterus and Fallopian tubes, of the prostate and vesicular 
seminales, and of the bladder, the clinical phenomena of which are mainly 
those of subacute inflammation of the same organs. 

Malignant disease of whatever kind soons spreads by continuity from 
the part in which it originates, and implicates all organs in its vicinity. 
If it commence in the uterus or vagina, it speedily infiltrates the surround- 
ing connective tissue, and then presently involves on the one hand the 
bladder, on the other the rectum, leading to free communications between 
these several viscera. Similarly malignant disease, commencing in the 
rectum or anus, in the bladder or parts at the neck of the bladder, or in 
the connective tissue investing these parts, or growing from the inner 
aspect of the pelvic bones, tends to the ultimate production of exactly 
similar results — to the formation in fact of a common excavation into 
which the several pelvic organs tend to discharge their contents. 

In the above cases, but mainly in that of malignant disease, other con- 
sequences are liable to ensue, more especially, perhaps, implication of the 
peritoneum, the laying open of vessels with the occurrence of more or less 
abundant hemorrhage, and the involvement of nerves, particularly those 
of the sacral plexus, with the production of local pain and tenderness and 
of pain taking the course of the sciatic nerve and mistakable for sciatica, 
and apt to be followed by wasting of the muscles, and cutaneous eruptions. 
Further, obstruction of the ureters with consequent hydro-nephrosis, re- 
tention of urine, impediment to the discharge of feces, tenesmus, irritability 
of the bladder, and oedema of the lower extremities or of the organs of 
generation, are all liable to occur in different cases at different periods in 
their progress. 



RHEUMATISM. 



783 



CHAPTEE VII. 

DISEASES OF THE ORGANS OF LOCOMOTION. 

• I. RHEUMATISM. {Rheumatic Fever.) 

Definition The terra rheumatism is often applied to all inflammatory 

or painful affections of the fibrous and muscular tissues which are not 
clearly referable to injury, gout, pyaemia, or any other well-recognized 
specific disease. With more precision it is used of inflammatory affections 
of the joints and other fibrous tissues which, depending apparently on some 
general or constitutional morbid state, have a tendency to migrate, or 
spread, as it were, by a kind of metastasis. 

Causation The essential causes of rheumatism appear to be the same 

as those of pneumonia and many other varieties of idiopathic inflamma- 
tion — namely, exposure to cold and wet, sudden chills, and long-continued 
exposure to any cooling influence which exercise or clothing fails to coun- 
teract. Getting wet through, and even having the feet damp and cold for 
any length of time, are common examples of the methods by which these 
agencies act. It must be allowed, however, that there are many predis- 
posing causes which exert an important influence over the production of 
rheumatism. If we may accept the results of statistical inquiries, it seems 
clearly proved that the children of rheumatic parents are on the whole 
more liable to suffer than those who come of a non-rheumatic stock. Age 
certainly has some influence, for young infants seldom if ever are attacked 
with rheumatism, and the old, when they suffer, suffer mainly from its 
chronic forms or from its sequelae. It is probably most common as an acute 
disease between the ages of ten and thirty. Sex has little influence, for 
although males on the whole are oftener affected than females, the differ- 
ence is probably entirely referable to the influence of their respective 
avocations. The most important of the predisposing causes are : first, the 
fact of having previously had an attack of rheumatism ; and, second, the 
condition of the patient's health at the time of exposure. It is well known 
that those who are suffering from scarlet fever, those who have gonorrhoea, 
and women immediately after child-birth, are peculiarly liable to be at- 
tacked with rheumatism, which then often becomes modified in character. 
Further, inasmuch as rheumatism depends essentially on vicissitudes of 
temperature and other allied conditions, it is of specially common occur- 
rence in cold, damp, and more particularly variable climates, and during 
those seasons of the year in which these conditions prevail. 

Morbid anatomy With one or two remarkable exceptions, to be pre- 
sently adverted to, the morbid anatomy of rheumatism calls for little 
comment. The affected joints present more or less hyperaemia of the 
synovial fringes and of the parietal layer of the synovial membrane, with 
excessive effusion of synovial fluid into their cavities and exudation of 
serum into the soft tissues around. The former fluid may either still pre- 



784 DISEASES OF THE ORGANS OF LOCOMOTION. 



sent the ordinary characters of synovia, or be turbid, milky, or flocculent. 
On microscopic examination, the epithelial cells of the synovial surface 
will be found swollen and plump, more or less fatty, and in some cases 
converted into granule cells ; the similar organisms, together with cells of 
pus or mucus, will be recognized in the synovial fluid. Changes also go 
on (according to Cornil and Ranvier) in the articular cartilages. These 
depend mainly on nutritive irritation of the cartilage cells, which swell 
up, assume a globular form, and according to the usual routine (com- 
mencing with division of the nuclei) become filled with secondary cells, 
which speedily acquire special secondary capsules. This condition does 
not involve the whole extent of cartilage; but occurs in scattered spots 
which, when they implicate the surface, reveal themselves to the naked 
eye by their prominence and comparative softness. Striation of the hya- 
line matter of the cartilage frequently attends this process ; and as this is 
mainly vertical in its direction, the cartilage may sooner or later acquire a 
velvety character. Rheumatic inflammation rarely results either in sup- 
puration or in permanent disorganization of the parts affected ; sometimes, 
however, a joint gets filled with pus ; sometimes ulceration of the cartilages 
takes- place; and sometimes the tissues external to the cavity become infil- 
trated with inflammatory lymph, matted together, and indurated. The 
effects of rheumatic inflammation, discoverable post mortem in most other 
fibrous tissues liable to be affected, are yet more trivial than those just 
described, and need no special consideration. 

The lesions of exceptional importance to which reference has been made 
are rheumatic affections of the heart and pericardium, and similar affections 
more rarely involving the lungs and pleurae. These are more particularly 
pericarditis, endocarditis, pleurisy, and pneumonia, which are all fully 
discussed elsewhere under their respective names. In acute rheumatism 
the blood always contains a large excess of fibrine, and it is common after 
death to find large fibrinous coagula in the cavities of the heart and large 
vessels. 

Symptoms and progress. — The symptoms of rheumatism are liable to 
great variety ; and especially they are liable to vary according as the rheu- 
matisin is confined to certain organs or tissues, or becomes a more general 
disorder. The differences, indeed, between these two forms of the disease 
are so great that many regard them as entirely distinct affections. 

The first form is generally traceable to the direct exposure to cold or 
wet of the part which becomes affected ; it is often chronic in its course 
and intractable, yet by no means necessarily attended with indications of 
constitutional disorder. Sometimes it affects the fibrous structures of the 
soles of the feet; sometimes the muscles of the lumbar region (lumbago) ; 
sometimes the great sciatic nerve (sciatica?) ; sometimes the intercostal : 
■ muscles; sometimes the muscles of the neck or shoulder, and especially, 
perhaps, the sterno-mastoid (stiff neck, torticollis); in all of which cases 
the local symptoms generally suffice for the identification both of the part 
affected and of the nature of the disorder. 

The more general and acute form of rheumatism, or ' rheumatic fever,'' 
as it is often called, sometimes comes on without warning, with elevation 
of temperature, alternate heats and chills, possibly rigors, and other usual 
indications of high fever, upon which, in a few hours, or perhaps a day or 
two, the characteristic local phenomena supervene. Sometimes, on the 
other hand, the acute symptoms of the general disorder suddenly super- 
vene upon slight rheumatic pains which have been for some time flying 



RHEUMATISM. 



785 



about the limbs, or have been limited to some muscle, or fibrous expansion, 
or joint ; or in the course of one of those varieties of localized rheumatism 
which have already been enumerated. But however the acute attack 
begins, its symptoms (apart from differences due to variation in severity 
and the occurrence of complications) present a great and striking simplicity. 

The parts which usually and chiefly suffer are the larger joints, espe- 
cially the wrists, elbows, ankles, and knees ; but no joint enjoys immunity ; 
and thus not only the hip and shoulder joints, and those of the spinal 
column, but those also of the clavicle, and those even of the carpus and 
tarsus, fingers and toes are all liable to be affected in the course of an 
attack. Further, the muscles of the limbs and other parts of the body by 
no means unfrequently suffer. The affected joints become very painful 
and exquisitely tender, so that the patient dares not move them and cannot 
bear that they be moved for him or touched, or even that his bed be 
shaken. They usually also get more or less obviously swollen, partly from 
effusion into the synovial cavity, partly from inflammatory infiltration of 
the surrounding tissues. This swelling is always most manifest in con- 
nection with those joints which are least thickly covered, especially, there- 
fore, those of the hands and feet, and the wrists, elbows, ankles, and knees. 
It is mainly in these same joints, and along the course of the sheaths of 
the tendons in relation with them, that superficial inflammatory conges- 
tion, which is often absent, is seen. Rheumatic inflammation is generally 
characterized, not only by its tendency to attack joints successively, but 
by its relatively short duration in any one joint. Thus, for the most part, 
each joint which is implicated becomes painful, swollen, perhaps obviously 
congested, and recovers its normal condition, all in the course of a few 
days or even a few hours ; and as a rule neither pitting nor desquamation 
ensues. And thus, again, we often find that only one or two joints are 
actually affected at a time ; or that, if the patient complains of general 
implication of the joints, some present the earliest indications of inflamma- 
tion, and others have attained their highest point, while most are in vari- 
ous stages of convalescence. It must not be forgotten that there is nothing 
protective in one attack of inflammation of a joint against subsequent 
attacks in the same joint ; and that hence the implication of any one of 
these organs may be repeated indefinitely in the course of the same attack 
of rheumatism. 

The other symptoms of the disease are in some respects almost as char- 
acteristic as the joint affection itself. The temperature is sometimes ele- 
vated only a degree or two, rarely rises above 105°, and generally falls 
short of this maximum by one or two degrees. It is liable to diurnal 
variations, which, although there is commonly a morning remission and an 
evening exacerbation, are on the whole irregular and untypical. Rigors 
are sometimes present. The skin almost invariably yields excessively 
copious sweats, which (although not actually more acid than healthy per- 
spiration) are attended with a peculiar and almost pathognomonic sour 
smell. These, by their profuseness and long continuance, generally induce 
a more or less abundant eruption of sudamina, which are often seated 
on congested bases, and then apt to be mistaken for eczema. The pulse 
is quickened, but not generally in adults to beyond 100 or 110 ; it is regu- 
lar, and as a rule more or less full and bounding. The respirations are 
somewhat accelerated ; the tongue is for the most part thickly coated with 
a moist creamy fur, and occasionally becomes dry, brown, and fissured. 
There is failure of appetite with excessive thirst. The bowels are usually 
50 



786 DISEASES OF THE ORGANS OF LOCOMOTION. 

constipated. The urine is scanty, of high specific gravity, high-colored and 
acid ; contains abundant urates, which, with crystals of uric acid, commonly 
deposit on cooling ; and presents an excess of urea and extractives, with a 
deficiency of chlorides. The patient is restless, sleepless, often pallid, wears 
an aspect of weariness, anxiety, or pain, but rarely presents delirium or 
other forms of mental disturbance. 

There is no definite limit to the duration of acute rheumatism. Some- 
times the patient recovers completely in the course of a day or two, or of a 
week ; more commonly the disease persists for several weeks ; and not un- 
frequently it becomes chronic, or is continued by successive relapses for a 
much longer period. It is generally observed that those cases in which 
the small joints are specially affected are of longer duration than those in 
which the larger joints mainly suffer. And, further, it not unfrequently 
happens that the febrile symptoms subside, while certain of the joints pass 
into a chronic condition of disease. Sometimes, owing to relaxation of the 
ligaments, certain joints remain more or less weak for an almost indefinite 
time: sometimes they continue stiff, swollen and tender; sometimes dislo- 
cation takes place, or the opposed surfaces cohere, or the soft tissues around 
get matted together with chronic inflammatory infiltration, and the joints 
consequently become fixed or otherwise permanently impaired. Suppura- 
tion seldom occurs. 

The complications of rheumatism are numerous and important. It may, 
however, be a question whether some of the so-called complications should 
not rather be regarded as integral parts of the disease equally with the in- 
flammation of the joints. Rheumatism is characterized essentially by in- 
flammation of the fibrous structures ; for the most part (as has been pointed 
out) it is those of the joints which suffer, but those connected with mus- 
cles, nerves, and fasciae are also liable to be involved. But of all, excepting 
those of the joints, the fibrous structures of the heart are most frequently 
implicated ; and, indeed, the heart in this respect might be regarded as 
one of the joints, for it is at least quite as liable to suffer as any one of 
them. In a large proportion of cases of acute rheumatism, especially in 
young persons, the heart becomes involved in the course of the disease ; 
occasionally the heart affection precedes that of the joints ; and it may even 
be the only local rheumatic manifestation. The exact numerical relation 
between heart disease and rheumatism is very difficult to determine, partly 
because slight attacks of pericardial inflammation and the scanty formation 
of warty masses on the auricular aspect of the mitral valve may very 
readily escape detection during life, partly because, when once an attack 
of rheumatism has occurred with distinct cardiac complication, it is often 
impossible to be certain whether or not in subsequent attacks further car- 
diac mischief has accrued. The endocardium suffers more commonly than 
the pericardium. The symptoms and consequences of the various cardiac 
lesions are all fully discussed elsewhere ; we may, however, point out that 
the supervention of cardiac complication is often attended with such slightly 
pronounced symptoms that it may either pass unnoticed or only be dis- 
covered on casual physical examination, while, on the other hand, its symp- 
toms are sometimes so grave and dangerous that they entirely, overshadow 
those of the general rheumatic attack. It need scarcely be said that, in 
every case of rheumatism, no matter how slight it is, the condition of the 
heart should be carefully watched. Pleurisy, pneumonia, and bronchitis, 
again, are not uncommon complications of acute rheumatism ; of these, 
pleurisy is probably the most characteristic. Peritonitis, too, occasionally 



RHEUMATISM. 



787 



supervenes ; as also jaundice and inflammation of the iris and sclerotic. 
Skin eruptions are specially apt to occur in the course of rheumatism. 
Reference has already been made to the frequent presence of sudamina ; 
other eruptions are mainly varieties of erythema or roseola, and especially 
of those varieties included by Hebra under the generic term of erythema 
multiforme. They are (to give them their specific names), e. papulatum, 
e. circinatum, e. marginatum, and, besides these, e. nodosum, and, accord- 
to Trousseau, erysipelas. 

It has already been pointed out that uncomplicated rheumatism, how- 
ever severe it may be, is rarely attended with cerebral disturbance ; never- 
theless it occasionally happens that symptoms referable to the central 
nervous organs break out with more or less of the suddenness that charac- 
terizes the onset of cardiac mischief, or that of each attack of joint inflam- 
mation. The occasional severity and fatal character of these nervous 
complications has not unnaturally led to the belief that the membranes of 
the brain or cord have become implicated in the same way as other fibrous 
structures, and it is not improbable that in some cases this actually takes 
place. It must be acknowledged, however, that post-mortem examination 
rarely gives evidence of such implication. In some cases (especially if 
there be recent heart disease or pulmonary complication) the patient may 
have that kind of delirium which so often attends pneumonia and various 
specific febrile diseases — a delirium mostly occurring between sleeping and 
waking, and from which he can be easily roused. In some cases the pa- 
tient has (more or less gradually developed) some form of mental aliena- 
tion ; while quiet in manner he gets suspicious and sly, taciturn and morose, 
has hallucinations, hears voices, sees visions, believes that he shall be 
poisoned or murdered or that the police are on his track, and may at any 
moment become violently maniacal. In some cases he becomes hemi- 
plegic, paraplegic, or choreic, or even suffers from tetanic spasms, with lock- 
jaw and risus sardonicus. From all such conditions he not uncommonly 
recovers completely, but sometimes they are the precursors of coma termi- 
nating in death. Fatal coma is ushered in variously, with lowness of 
spirits, with insanity, with delirium or typhomania, with giddiness, head- 
ache, singing in the ears, or affection of the sight, with paralysis, or with 
convulsions. Sometimes it comes on suddenly with an apoplectic seizure: 
and death may ensue in from twelve to twenty-four hours, or even in four 
or five hours from the first appearance of the nervous symptoms. It has 
been observed that in some of these cases there is during the attack either 
an excessive flow of limpid urine, looseness of bowels, or both of these 
conditions. 

Lastly, in relation to the complications of rheumatism, it must be pointed 
out that, although as a rule the temperature in this disease does not exceed 
105°, it occasionally rises with great rapidity to 107° or 108°, or even 
110°, 111°, or 112°, and that such excessive rises are almost invariably 
of fatal augury. They always occur in association with some of the com- 
plications which have already been discussed, such as acute cardiac or 
pulmonary disease, or, above all, cerebral symptoms. Their connection 
with the first two complications is not difficult to understand ; their con- 
nection with the last is certainly obscure, and none the less so that in some 
of the cases with fatal brain symptoms the temperature presents no un- 
wonted rise. It seems probable, however, that both the nervous phe- 
nomena and the hyperpyrexia are alike dependent on molecular disinte- 
gration referable to the presence of some poisonous matter developed in 



788 



DISEASES OF THE ORGANS OF LOCOMOTION. 



the course of the disease and circulating with the blood ; in connection with 
which suggestion it may be pointed out that the skin not only as a rule 
ceases to perspire profusely, but often becomes dry and harsh. Dr. H. 
Weber draws attention to the close resemblance subsisting between these 
cases and cases of sunstroke. The relations of rheumatism, through car- 
diac disease, with chorea and embolism are fully considered elsewhere. 

It will be readily gathered from the foregoing account that, independ- 
ently of all so-called complications, rheumatism is liable to present, within 
certain limits, many varieties of character. It may be acute, or it may 
assume a chronic form, and may, in fact, continue with relapses for months 
or years ; it may attack chiefly the larger joints, or it may specially, as it 
were, select the smaller ones ; instead of temporarily involving joint after 
joint in irregular succession, it may spend its force on one or two and damage 
them irremediably ; it may cause inflammation, mainly of the synovial 
membranes, with effusion into the synovial cavities in one case, mainly of 
the soft tissues around the joints, with infiltration of these tissues, in 
another, or mainly of the fibrous sheaths of muscles or nerves, in a third; 
when developed in connection with gonorrhoea, it is peculiarly apt to be- 
come intractable and to lead to permanent injury of the affected joints ; 
when it arises after childbirth, or in the course of some of the specific 
fevers, the inflammation it evokes may assume a suppurative character. 
Yet, however long the duration of rheumatism, or however severe or vari- 
ous it may be in its local manifestations, it is seldom dangerous to life, un- 
less it be through the instrumentality of one or other of the more serious 
complications which have been discussed ; but these are fatal in a high 
degree, sometimes immediately, m'ore frequently at a later period of life, 
in consequence of the more or less slowly developed effects of the organic 
lesions of vital organs which they induce. 

Pathology. — It remains to say a word or two in reference to the path- 
ology of rheumatism. Is it a local disease, or is it a constitutional dis- 
ease? Does it depend on the presence' of some specific poison circulating 
in the blood, on the action of the bloodvessels, on the action of the vaso- 
motor nerves, or on what? These are questions of considerable difficulty, 
and impossible to discuss fully in the space at our disposal. It seems to 
us, however, that there is little or nothing in rheumatism, in respect of its 
proximate cause, to distinguish it from pneumonia, bronchitis, nephritis, 
erysipelas, or any other example of local inflammation caused by exposure 
to cold, or cognate conditions. If these be constitutional diseases, so is 
rheumatism; if they be local diseases, rheumatism also is, in the same 
sense, a local disease — a disease, that is to say, involving a special tissue, 
but one which happens to be largely distributed throughout the system. 
[Although much may be said in favor of this theory, it may be objected 
to it that while, in the purely local diseases, as, for instance, bronchitis, 
the inflammation extends occasionally from the larger to the smaller tubes, 
it does not subside in the former, but continues with undiminished intensity. 
In rheumatism, on the other hand, all inflammatory action may disappear 
from the joint first affected, leaving it apparently in a perfectly healthy 
condition ; the general character of the disease being shown in the coin- 
cident or subsequent involvement of other joints.] That the blood be- 
comes abnormal in rheumatism is certain, and especially it is certain that 
it contains an excessive quantity of fibrine and of the products of disinte- 
gration of tissue; but these are the mere consequences of the rheumatic 
process, and have no more to do with the production of rheumatism than 



RHEUMATISM. 



789 



the similar condition of the blood in pneumonia has to do with the produc- 
tion of pneumonia. The proximate cause of rheumatism has been largely- 
held to be a poisonous substance circulating in the blood, and the copious 
perspirations have been regarded as an effort of nature for the elimination 
of this pojson ; it has even been maintained that the poison is either lactic 
or some other acid. No excess, however, of lactic or any other acid has 
as yet been detected in the blood or perspiration of rheumatic patients, and 
if there be a rheumatic poison, which is possible, its discovery is in the 
future. 

Treatment Innumerable remedies have been vaunted for the cure of 

rheumatism, yet it remains one of the most unmanageable complaints 
which physicians can be called upon to treat. Some advocate the use of 
iodide or bromide of potassium in frequent medium doses ; some that of 
nitrate of potash in daily quantities varying between 1 and 3 ozs. largely 
diluted and taken as a drink ; some that of alkalies, and more especially 
of the bicarbonate of potash in doses of from 20 to 30 grains given every 
hour or two; some recommend colchicum, some veratria, some guaiacum, 
some quinine, and some opium, in quantities sufficiently large and suffi- 
ciently frequently repeated to induce their respective specific actions. Dr. 
Garrod prefers a combination of quinine and bicarbonate of potash in 
about 5- and 30-grain doses respectively. Others trust mainly to local 
treatment : simple hot fomentations, hot fomentations with which alka- 
lies and laudanum have been mixed, counter-irritation by means of spirit 
or turpentine, mustard plasters, or blisters. Blisters especially have been 
recently brought into prominent notice by Dr. Herbert Davies. Others, 
again, trust to ' packing,' or to vapor, hot-air, or hot-water baths. 

By far the most valuable and efficacious treatment of acute rheumatism 
is that by salicylic acid or salicylate of soda. This, if given in sufficiently- 
large and frequently repeated doses, has a marvellous power of reducing 
fever, and, at the same time, of relieving and cutting short the local in- 
flammations and the pain attending them. Of the above preparations, 
the salicylate is the most convenient and the best ; but either may be 
given to an adult in 20- or 30-grain doses every two or three hours. The 
continuance of the drug must be determined by its effects. So soon as 
the temperature has fallen to the normal and pain has subsided, it must 
either be discontinued or given in smaller or less frequent doses. It is 
necessary to watch the patient carefully during its administration, for vari- 
ous undesirable, if not dangerous, symptoms are liable to supervene and to 
compel the discontinuance or diminution of the medicine. Among these 
the more important are albuminuria, sickness, noises in the ears, deafness, 
and especially delirium. 

As a general rule a rheumatic patient should be kept in a comfortably 
arranged bed, well covered with bedclothes, and protected if necessary by 
mechanical means from their undue pressure ; perspirations should be 
encouraged, and the inflamed joints covered with cotton-wool ; pain should 
be relieved and rest obtained by the administration of opiates; thirst 
should be appeased and secretions encouraged by the administration of 
abundant diluents, such as lemonade, soda-water, milk, beef-tea, and 
broths ; and nutrition should be maintained by the use of such food (mostly 
fluid and farinaceous) as the patient can be persuaded in reason to take. 
He should be placed in a warm room, well ventilated, yet free from 
draughts, from which indeed he should be protected by curtains. In addi- 
tion some one of the lines of medicinal treatment above indicated may be 



790 



DISEASES OF THE ORGANS OF LOCOMOTION. 



pursued, or counter-irritation may be practised. As regards the use of 
blisters, we may state that they do, according to our own experience, 
afford almost immediate and marvellous relief to the pain of the inflamed 
joints in the neighborhood of which they are placed, and that they may 
be applied to joint after joint in the progress of rheumatism without any 
ill effect whatever, but that they do not cut short the progress of the in- 
flammation which they relieve, and have no influence whatever over the 
general progress of the rheumatic attack. [The bromide of ammonium in 
doses of from 15 to 20 grains repeated every three or four hours will often 
be found, in connection with the alkalies, a valuable remedy in rheuma- 
tism. While it cannot be asserted of it that it cuts the disease short or 
entirely prevents the occurrence of cardiac complications, it certainly re- 
lieves pain and diminishes restlessness.] It may be added that colchicum 
is said to be specially efficacious when the rheumatism is attended with 
marked dropsy of the synovial cavities; and that iodide of potassium or 
guaiacum is considered to be chiefly beneficial in chronic cases. During 
convalescence from rheumatism, great care should be taken to avoid cold 
and draughts, and the patient should be warmly clothed in flannel. He 
should, moreover, be put on a course of quinine and iron or some other 
tonic, well fed, and if necessary removed for a time at least to some more 
genial neighborhood. 

When rheumatism becomes chronic, or rheumatic pains are a source of 
trouble from time to time, or the patient suffers from rheumatism of certain 
fasciae, muscles, or nerves, various measures are open for us to adopt for 
his relief. Hot-air baths, vapor-baths, hot-water baths, Turkish baths 
frequently repeated, are often exceedingly valuable. Counter-irritation, 
especially by means of blisters or stimulating liniments, hot fomentations, 
the application of belladonna or aconitia, or even the removal of blood by 
leeches, may be of more or less benefit. Opiates, especially given by sub- 
cutaneous injection, are often of marvellous efficacy. For general treat- 
ment, we may have recourse to the drugs which are supposed to be 
serviceable in the acute form of the disease; but those which are most 
likely to be of use now are probably iodide of potassium, guaiacum, qui- 
nine, iron, and other varieties of tonics. 

For the treatment of the various complications of rheumatism we must 
refer the reader to the articles in which these affections are specifically 
considered. We may, however, observe that when cerebral or spinal 
symptoms manifest themselves, it is generally advisable to act freely on 
the bowels, to employ revulsive treatment, and to place our trust (as re- 
gards internal remedies) in opium and diffusible stimulants. If hyper- 
pyrexia come on — if the temperature rise above 105° or 106° — then it 
may be advisable to reduce it by the application of external cold. This 
may be done either by sponging the patient's bod}' with tepid or cold 
water, or by surrounding him with sheets kept moist and cool by pouring 
water over them from time to time, or best of all by placing him in a bath, 
the temperature of which may at the beginning stand at about 98°, but 
which is allowed to cool gradually to 60° or 70°. The patient may be sub- 
jected to such treatment for half an hour or even an hour at a time ; but 
the propriety of continuing or determining it must be judged of by his 
condition. It should not be continued after he begins to shiver or look 
cold, or after his temperature has been reduced to the normal. But if the 
temperature rises it may need to be repeated frequently and at short inter- 



RHEUMATOID ARTHRITIS. 



791 



vals. There is no doubt that patients are often temporarily benefited by 
this treatment in a remarkable degree. It is less certain that their ulti- 
mate recovery is materially promoted by it. 



II. RHEUMATOID ARTHRITIS. {Chronic Rheumatic Arthritis.) 

Definition. — This affection, which consists essentially in a chronic irri- 
tative outgrowth of the cartilages andjjynovial fringes of the joints, asso- 
ciated with progressive destruction of" those parts of the cartilages which 
are most subjected to pressure, has been described under various names, 
among which may be mentioned i chronic rheumatism,' 1 chronic rheu- 
matic arthritis,' 'nodular rheumatism,' and 'arthritis deformans.' 

Causation. — It occurs far more frequently in women than men ; and 
comes on in them mostly, it is said, about the period when menstruation 
ceases. It may, boAvever, commence at any time of life, and has been 
recognized even in young infants. Its cause is obscure. But it is certain : 
that many of those who suffer from it have had acute rheumatism of the 
ordinary type at some earlier period of life ; that in some cases its com- 
mencement maybe clearly traced to those conditions which are productive 
of acute inflammation ; and that most of those who suffer from it are espe- 
cially sensitive to vicissitudes of temperature and changes of season. The 
subjects of this affection are always more or less anaemic, but whether 
anaemia and debility are to be regarded as anything more than predisposing 
causes in some cases, or as consequences in others, is exceedingly doubtful. 

Morbid anatomy. — In rheumatoid arthritis the morbid processes are 
confined to the articular cartilages and synovial fringes. The central areae 
of the cartilages, to a variable but gradually increasing extent, acquire a 
velvety or villous character, get worn down by degrees, and finally disap- 
pear, leaving the subjacent bone exposed, which then assumes an ivory- 
like compactness and smoothness. But while the central portions are thus 
disappearing, the margins form nodular outgrowths of extreme irregularity, 
in size, shape, and arrangement. The synovial fringes take part in the 
hypertrophic process, and form bulbous or pyriform excrescences, varying 
in size, and often collected into clusters of more or less complexity. They 
are at first fibrous, but soon become the seat of cartilaginous growth ; and 
both they and the ecchondroses tend to ossify, and often after a while get 
converted wholly into bone. These outgrowths in some cases blend with 
the osseous structure of the epiphysis, in some cases remain connected 
with it by fibrous cartilaginous pedicles, and occasionally break off. The 
gradual progress of the disease leads to the lateral expansion of the joint- 
surfaces and to extreme irregularity with nodular enlargement of the 
margins of the joint-ends of the bones, and to more or less dislocation, 
deformity, and immobility. All joints are liable to be thus affected — those 
of the hands and feet, those of the arms and legs, those of the jaws, and 
even those of the spine. The early changes which take place in the car- 
tilages in this affection are enlargement and proliferation of the cartilage 
cells. In the central areae of opposed cartilages, where they are subject to 
constant mutual pressure, the enlarging cavities which contain the multi- 
plying cells communicate with one another in vertical linear series, and 
opening at the surface discharge their cellular contents into the synovial 



792 



DISEASES OF THE ORGANS OF LOCOMOTION. 



cavity; by this means the hyaline substance becomes honeycombed by 
vertical pits, or split into vertical columns, and thus acquires its charac- 
teristic velvety appearance. The proliferation, however, of the cartilage 
cells at the periphery (where growth is less interfered with) and of the 
synovial fringes results in permanent overgrowth of these parts, and in 
that further development of them which has been described. 

Symptoms and progress The symptoms of rheumatoid arthritis are 

mainly those which are due to the gradual advance of deformity, disloca- 
tion, and loss of mobility in the affected joints, and to a tendency to 
gradual implication of most or all of the joints of the body. But with 
these are associated: more or less pain and tenderness, rarely acute, in the 
affected parts, coming on at irregular intervals and attended with more or 
less febrile disturbance ; wasting of the muscles connected with the diseased 
joints, with spasmodic cramp-like pains in them; and anaemia. 

The disease, as has been stated, may follow immediately or remotely 
on an attack of acute rheumatism ; but in many cases it is chronic or sub- 
acute from the beginning. The patient complains 7 perhaps, of slight pain, 
tenderness, and swelling in one or more of the joints, probably the knees, 
wrists, or fingers, and of slight feverishness ; but ere long, with rest and 
confinement to the house, the symptoms subside. Then, after a short in- 
terval, the phenomena recur, probably with greater intensity ; and possibly 
other joints besides those first affected now become implicated. Again, 
perhaps, the symptoms subside. These attacks, however, continue to recur 
for the most part at shorter and shorter intervals, to implicate a gradually 
increasing number of joints, and to leave them (in the intervals of sub- 
sidence) still swollen and tender, and to render them more and more use- 
less. At length, after the lapse of some months, or it may be years, the 
patient becomes thoroughly crippled ; most of his joints, or all of them, 
are swollen, distorted, and more or less rigidly fixed ; all his muscles are 
wasted ; and his arthritic and muscular pains, now never wholly absent, 
are liable to frequent exacerbations, especially in connection with changes 
of temperature. 

Rheumatoid arthritis usually commences in the hands, and more espe- 
cially in the metacarpophalangeal joints of the fore, middle, and ring 
fingers ; the wrists and knees are also early implicated. The upper ex- 
tremities as a rule suffer before the lower extremities ; and although the 
metatarsophalangeal joint of the great toe generally becomes affected in 
the course of the complaint, it is rarely or never the primary seat of attack. 
The articulations of the jaws and of the spine are for the most part impli- 
cated at a late period. The nodulated condition of the joint ends of the 
bones is usually most distinctly marked in the finger-joints, the ball of the 
great toe, the wrists, elbows, and knees ; it is in these same joints, too, 
and in the hips, that imperfect dislocations most commonly pccur. When 
the joints are rigid and fixed, they usually occupy the position of flexion ; 
the thighs are flexed on the abdomen, the legs on the thighs, and the fore- 
arms on the upper arms — in the last case with some degree of pronation. 
The hands generally continue in a straight line with the forearms, or 
present some degree of tilting towards the ulnar side, but the fingers 
acquire various and strange distortions. The most frequent form is that 
in which, while the first and third phalanges are flexed, the second or 
intermediate phalanx is extended. The thumb is usually extended. Rheu- 
matoid arthritis, though generally a progressive disease, and incapable of 
cure, occasionally remains limited to one or two joints, or becomes arrested 



GOUT. 



793 



in its progress, or even (so far as the structural changes which have taken 
place permit) undergoes a more or less perfect cure. 

Pathology The relation between rheumatoid arthritis and acute rheu- 
matism is not easy to determine. It is quite certain that acute rheumatism 
very seldom induces the characteristic morbid processes of the former dis- 
ease ; and that rheumatoid arthritis is rarely attended with the profuse 
perspirations, the febrile urine, and the visceral complications which belong 
to acute rheumatism. On the other hand, rheumatoid arthritis is essen- 
tially an inflammation of the very structures which are mainly implicated 
in acute rheumatism ; the joints become successively and symmetrically 
involved as they do also in the latter disease ; and, with reference to the 
absence of sour perspirations and the like, it must not be forgotten that 
these may be entirely absent in cases of chronic, subacute, or muscular 
rheumatism ; and as regards visceral complications, Trousseau shows that 
peri- and endo-carditis are sometimes present in these cases, and that even 
cerebral mischief occasionally supervenes. Moreover, as Garrod points 
out, inflammation of the sclerotic and other fibrous textures now and then 
attends rheumatoid arthritis. On the whole, we are inclined to regard it 
as a chronic inflammatory process, which is not necessarily, but is in a 
large number of cases, a sequela of acute rheumatism. 

Treatment. — For the general treatment of rheumatoid arthritis we must 
refer to what has already been said in reference to the treatment of acute 
rheumatism. For the most part, however, we must trust to local meas- 
ures and to constitutional treatment calculated to improve the general 
health of the patient. Locally, friction, counter-irritation, the inunction 
of the parts with preparations of iodine or mercury, the maintenance of 
the joints in one position by suitable apparatus, are all more or less im- 
portant. Hot fomentations again are valuable, and especially perhaps (as 
recommended by Trousseau) the burying of the joint in sand heated up to 
140° or 150°, keeping it there for an hour or two at a time, and repeating 
the operation three times a day. 



III. GOUT. (Podagra.) 

Definition Gout is a disease which is characterized by the deposition 

of urate of soda in a crystalline form in the cartilages and other textures 
of joints, and elsewhere among the fibrous tissues, and by recurrent attacks 
of articular inflammation. It is usually attended also with constitutional 
symptoms and grave lesions of important organs. 

Causation. — Gout is mainly a disease of middle and advanced life, and 
of the male sex, and generally comes on between the ages of thirty and 
forty -five. It is sometimes, however, met with at or about the period of 
puberty, and has occasionally made its first appearance as late as the 
eightieth or even ninetieth year. In women it rarely shows itself until 
after the cessation of the menstrual flow. The influence of hereditary 
predisposition in the production of disease is probably nowhere more 
clearly evinced than in the history of gout ; and, indeed, Dr. Garrod's 
experience leads him to the belief that more than half the total number 
of gouty patients have clearly inherited the gouty proclivity from their 
parents. On the other hand, it is certain that gout is largely induced by 



794 



DISEASES OF THE ORGANS OE LOCOMOTION. 



habits of life, and that, even where an hereditary taint exists, the influence 
of habits in accelerating the first attack or in postponing it, or even in 
preventing the occurrence of the disease, is still very considerable. As 
regards habits, it seems to be universally admitted that long-continued 
indulgence in alcoholic beverages, long-continued over-eating, especially 
of animal food and of rich dishes, and prolonged insufficiency of exercise, 
are (especially in combination) powerful agents in the causation of gout. 
It is, however, generally held that all alcoholic beverages are not equally 
injurious in this respect, that the distilled spirits are comparatively innoc- 
uous, that the light wines, claret, hock, moselle, and the like, are also 
fairly wholesome, but that strong wines, sherry, and madeira, and above 
all port, and malt liquors, are all virulent gout-producers. But on what, 
it maybe asked, do the injurious effects of alcoholic beverages depend? 
If, as seems reasonable to assume, they are due to the alcohol which they 
contain, how can we accept the statement that the distilled spirits are 
almost harmless, while bitter ale and porter are highly poisonous? If, on 
the other hand, the alcoholic constituent be acquitted, must we refer them 
to the comparatively simple matters which give to alcoholic beverages their 
respective flavors, their colors, or their body — matters which are, most of 
them, not special to such beverages, are most of them certainly not un- 
wholesome, and individually form an insignificant percentage of the whole? 
"We must confess our distrust of the evidence which, while accusing alco- 
holic drinks of causing gout, acquits the alcohol itself. On similar grounds 
we venture to submit, notwithstanding almost universal testimony to the 
contrary, that port is no more injurious than sherry or madeira, or other 
wines of equal strength. It is probably less in consequence of the port 
which they drink than of the association in their case of over-drinking, 
over-feeding, and want of exercise, that the higher classes suffer more 
frequently from gout than those who occupy a lower station of life. It 
must be added that fatigue, exposure, indigestion, and whatever impairs 
the health, and injuries inflicted on joints, are all apt to bring on attacks 
of gout in those who are liable to the disease. The impregnation of the 
system with lead appears to be peculiarly powerful in inducing a suscepti- 
bility to gout. 

Morbid anatomy The morbid phenomena of gout are chiefly mani- 
fested in the joints and surrounding tissues. The earliest appearances are 
furnished by the superficial portions of the articular cartilages, which seem 
dusted, so to speak, with spots and patches of an opaque white color. As 
the morbid process extends, the cartilages become more and more gene- 
rally infiltrated, until they look like a mere mortary incrustation of the 
joint-surfaces of the bones. Later still, similar mortary patches appear 
imbedded in the substance of the synovial ' membranes, and gradually 
involve them more or less completely ; and at the same time, or later, 
masses (which eventually vary perhaps from the size of a pea to that of a 
filbert) accumulate in the substance of the soft tissues surrounding the 
joints, in the bursas, and in the cancellous tissue of the subjacent bones. 
The changes do not end here. The infiltrated cartilages lose their vitality, 
become brittle, gradually eroded, and finally removed, exposing the bone 
beneath, which itself may sooner or later undergo destructive changes. 
The margins of the affected cartilages, on the other hand, not unfrequently 
become irritated into overgrowth, and form nodular enlargements like 
those of rheumatoid arthritis. The accumulations of mortary matter in 
the tissues about the joints, which constitute chalk-stones or tophi, grad- 



GOUT. 



795 



ually provoke erosion of the swollen and congested tissues which cover 
them, and finally an opening is formed from which they escape. The ap- 
pearances above described are due to the deposition in the substance of the 
cartilages, and elsewhere where such deposits are found, of needle-like 
crystals of urate of soda, arranged for the most part in dense, opaque, 
stellate clusters. This deposition appears to commence within the cells, 
and, although the needle-like rays extend thence into the surrounding 
intercellular substance, it is still to the cells that the crystalline formation 
is mainly confined. Gouty formations, as a rule, first manifest themselves 
in connection with the metatarso-phalangeal joints of the great toes, 
usually the right, and may remain thus limited for a considerable length 
of time. But gradually other joints (and for the most part with more or 
less symmetry of arrangement) become involved — the smaller ones, as a 
rule, first, the larger ones at a later period. Thus, after the metatarso- 
phalangeal joints of the great toes, the other toe-joints and the joints of 
the tarsus, fingers, and carpus, the sterno-clavicular articulations, the 
ankles and wrists, the knees and elbows, and finally the hips and shoulders, 
and other joints, become successively the seats of disease. The joints 
connected with the laryngeal cartilages also occasionally suffer. Gouty 
deposits, moreover, are apt to form along tendons, chiefly in the neighbor- 
hood of gouty joints ; beneath the periosteum of the tibias and other bones ; 
in the course of the smaller vessels and nerves ; and in connection with 
the perichondrium of the external ear, the tarsal cartilages, and the sclerotic 
coat of the eye. In the ear they mainly affect the convex edge of the helix ; 
in the tarsal cartilages, those portions which immediately adjoin the edges 
of the palpebral orifice. 

The ultimate effects of gout upon the joints are in most cases very seri- 
ous. They get irregularly swollen, partly from inflammatory and gouty 
infiltration of the tissues which surround them, partly from the changes 
which have been going oh in their interior. Accordingly the irregularity 
is not, as in rheumatoid arthritis, limited to the joint-ends of bones, but 
occupies the intermediate regions at least equally, and probably in a still 
greater degree. The articulations become more or less fixed, generally in 
some inconvenient position, and may even be dislocated : these results 
being due in various degrees to the changes which have taken place in the 
soft tissues around, to uratic infiltration and loss of suppleness in the 
synovial membranes and ligaments, and to actual ankylosis, which some- 
times follows the complete removal of the cartilages. Chalk-stones form 
more or less abundantly in the tissues external to the joint-cavities, adding 
to the apparent bulk of the joints and to their knotty irregularity, and 
finally become discharged through ulcerated openings, which, still secret- 
ing large quantities of chalky matter, may remain patent for years. The 
deformities and other ulterior changes here enumerated occur most fre- 
quently, earliest, and with greatest severity, in the joints of the hand ; 
next in order in those of the feet ; then in the wrists, elbows, ankles, and 
knees ; and finally in the hips and shoulders. 

It is rare to find in the necropsy of gouty persons that all other organs 
save those of which the morbid conditions have just been described are in 
a perfectly healthy condition. It could scarcely be expected, indeed, 
when one looks to the circumstances under which, as a rule, gout arises, 
that the internal viscera should escape those degenerative changes which 
so commonly follow long-continued persistence in bad habits, or attend 
that tendency to premature decay which some of us unfortunately inherit. 



796 



DISEASES OF THE ORGANS OF LOCOMOTION. 



It is not surprising, therefore, that gouty patients are liable to have de- 
generated arteries, valvular lesions and other morbid conditions of the 
heart, emphysema of the lungs, cirrhotic liver, and contracted granular 
kidneys. The last lesion, indeed, is so common in gout that it is not un- 
frequently termed the ' gouty kidney.' The kidneys of gouty patients, 
moreover, often present, especially in the cones, linear aggregations of a 
buff-colored material, which is, in fact, a deposit of urate of soda, either 
in stellate crystals in the matrix, or in an amorphous form in the tubules. 
Concretions of the same material sometimes adhere to the mammillary 
processes. These precipitates are not, however, characteristic of gout, 
and are frequently found in persons who have no gouty tendency, and even 
in new-born children. 

Symptoms and progress. — It has been distinctly shown by post-mortem 
examination that the gouty deposit takes place in the articular cartilages 
long before the joints become inflamed or give any clinical evidence of the 
nature of the process which is going on in them — a fact which is confirmed 
by the total freedom from inflammation and pain which usually attends the 
formation of those uratic concretions which are met with in connection 
with the aural cartilages and periosteum. And hence it may be assumed 
that at any rate a very large proportion of those who ultimately become 
distinctly gouty have been really gouty for a considerable time previously 
to the first considerable outbreak ; and hence also it is easy to understand 
that in many cases the first so-called ' attack' may have been preceded by 
premonitory symptoms such as occasional -pain or tenderness in one or both 
great toes, or other of the smaller joints, such as those of the wrists, 
ankles, or clavicles. 

The first 1 attack of gout ' almost invariably comes on suddenly, with 
pain and swelling in the ball of one of the great toes, usually the right. 
Moreover it occurs for the most part early in the year, and almost without 
exception in the night time. The patient goes to bed probably in his 
usual health, but wakes about two or three o'clock in the morning with 
severe pain in the metatarso-phalangeal joint of one of his great toes. The 
agony is sometimes so intense that he dares not move the affected limb ; 
he cannot bear the pressure of the bedclothes, or even the slightest jar to 
his bed or the slightest movement in his chamber ; his sufferings, too, are 
often aggravated by cramps and involuntary startings in the muscles of the 
leg ; he becomes restless and hot, shivers, sometimes has repeated rigors, 
and, after tossing about for some hours, falls into a perspiration; and then, 
somewhere about the time he should be thinking of getting up, he falls 
into a gentle sleep, from which, in the course of a few hours, he awakes, 
refreshed and comparatively easy, but with the great toe joint swollen, 
tense, and vividly red, and with the superficial veins of the foot, and prob- 
ably some of those extending up the leg, unusually distinct and full. He 
most likely continues comparatively well throughout the day, and may 
even be able to limp about on his maimed limb ; but with the advance of 
evening, or it may be in the early hours of the ensuing morning, he has a 
more or less severe recurrence of the local pain and febrile symptoms 
which marked the first attack, to be again followed after the lapse of a few 
hours by a second intermission. These nocturnal exacerbations, succeeded 
by matutinal remissions (lasting usually till evening), come on with com- 
parative intensity for two or three successive nights, and then gradually 
diminish in severity, until at the end probably of a week or ten days all 
febrile symptoms and all acute suffering have passed away. But the 



GOUT. 



797 



affected joint probably remains swollen, weak, and tender for a week or 
two longer. During the attack, the ball of the toe becomes, as has been 
stated, tense, swollen, vividly red, generally more or less shiny, and exqui- 
sitely painful and tender. Most of these conditions attain their maximum 
usually by about the second day, after which the pain and tenderness 
gradually subside, and the redness acquires a dusky hue; but the swelling 
probably still increases for a time, and even extends far beyond the limits 
of the seat of inflammation. Much of this, indeed, is now due to simple 
oedema, and the parts pit on pressure. The swelling disappears in its turn 
and desquamation follows. The febrile symptoms, from which the patient 
suffers during his attacks, are, as has been indicated, of a remittent type, 
and attended not only with shiverings or rigors and perspirations, but fre- 
quently also with furred tongue, loss of appetite, thirst, constipation, and 
a febrile condition of urine. 

It occasionally happens : that even in the first attack of gout both great 
toes are simultaneous or sequentially implicated, or that not only the toes, 
but the ankles, knees, and other joints successively suffer, in which case 
especially the affection may present a close resemblance to acute rheu- 
matism ; or, again, that the first attack, instead of subsiding speedily, as 
it usually does, continues by a series of successive outbreaks of no great 
intensity in the same joint for weeks or months. It sometimes also hap- 
pens that the first attack of gout is in the ankle, knee, or some other joint 
than that of the toe — a circumstance which in some cases is obviously due 
to an injury or some other lesion of the part. 

The first attack of gout may also be the last. But far more commonly 
a second attack supervenes sooner or later, occasionally not for eight or 
ten years, sometimes after an interval of a few months only, most frequently 
at the end of a year or two. To the second attack other attacks succeed, 
at first separated from one another by intervals of probably about twelve 
or six months, but gradually approaching one another until at length the 
„ patient, though still liable to exacerbations, is perchance never actually 
free from suffering. Further, each successive attack, as a rule, implicates 
a larger and larger number of joints : those joints, however, which have 
been most frequently affected generally suffering most severely. Gradually 
these grow lumpy, deformed, and rigid; the patient becomes more and more 
crippled ; chalk-stones form and discharge themselves through ulcerated 
openings; the general health deteriorates; and death, usually dependent 
on some visceral complication, finally ends the scene. The pain which 
attends the later attacks of gout, although more continuous, is rarely so 
acute as that of the earlier outbreaks; and, further, the degree of disorgani- 
zation of joints and the amount of urate of soda deposited in or about them 
are by no means necessarily related to the frequency or severity of the 
attacks of inflammation from which the joints have suffered. 

The condition of the urine in gout, which has been carefully investigated 
by Dr. Garrod, has already been referred to. During the febrile paroxysms 
it is scanty and high-colored, of high specific gravity, and generally deposits 
on cooling an abundant sediment. It contains relatively to its bulk an 
excess of urates ; but the total amount of these passed in the twenty -four 
hours is absolutely less than in health. The urea is also probably some- 
what diminished. In the chronic form of the disease the urine is pale, 
abundant, of low specific gravity, generally yielding no deposit, and pre- 
senting (as in the febrile stage) a diminished daily quantity of urates and 
urea. It often contains a small amount of albumen, with hyaline or 



798 



DISEASES OE THE ORGANS OE LOCOMOTION. 



granular casts. The condition of the blood lias also been investigated by 
Dr. Garrod, who finds: that during the inflammatory attacks of acute gout 
it contains urate of soda in relatively large abundance, while none can be 
detected in it previous to the occurrence of inflammation or after its sub- 
sidence; but that, when the gout assumes a chronic or inveterate character, 
urate of soda is present in the blood both during the exacerbations and in 
the intervals. He has also found in the blood oxalic acid, which he refers 
to the decomposition of the retained uric acid, and urea the presence of 
which is probably always dependent on associated renal disease. 

In the foregoing account many of those phenomena which by some 
authors are regarded as among the most important in the history of gout 
have been passed over in almost complete silence. We refer, on the one 
hand, to the premonitory symptoms referable to functional lesions of various 
organs, and, on the other, to the various sequelae or complications which 
from time to time present themselves. Gouty persons are usually more or 
less dyspeptic ; and it is not unnatural, therefore, that dyspeptic symptoms 
should in a large number of cases precede the gouty paroxysms, and persist 
more or less during the intervals between successive attacks. Among the 
premonitory symptoms, therefore, maybe enumerated epigastric discomfort 
pain, flatulence, and eructation, with more or less constipation or disturb- 
ance of the bowels, palpitation, dyspnoea, headache, drowsiness, restless- 
ness, moroseness, irritability, and violence of temper. Such symptoms 
often attend the gouty outbreak, but, on the other hand, they are said fre- 
quently to be removed by it. The sequelae and complications of gout are 
numerous, and may be considered seriatim in connection with the organs 
which are their seat. In connection with the nervous system occur vertigo, 
headache, convulsions, mania, apoplexy, anaesthesia, paralysis, hyperes- 
thesia, lumbago, sciatica, and various other neuralgic pains ; in connection 
with the vascular system, palpitation, syncope, angina pectoris, and various 
forms of structural cardiac disease : in connection with the lungs, asthma, 
bronchitis, and emphysema ; in connection with the gastro-intestinal tract, 9 
dyspepsia, gastralgia, irregularity of bowels, and haemorrhoids. Further, 
the liver not unfrequently becomes indurated or cirrhotic, and jaundice, 
ascites, or melaena may ensue ; the kidneys in a large number of cases get 
contracted, granular, and incompetent, and the patient tends to suffer from 
the usual symptoms of chronic Bright's disease ; the bladder becomes irri- 
table or inflamed ; concretions form in the urinary passages, or mucous or 
purulent discharges take place from them ; and, lastly, skin affections often 
arise, especially perhaps chronic eczema and psoriasis. But none of the 
symptoms or lesions here enumerated is peculiar to gout ; and their fre- 
quent coexistence with it is doubtless in large measure dependent on the 
fact that sufferers from gout are on the whole persons whose internal organs 
are in a greater or less degree in an abnormal condition, and whose bodily 
functions tend, therefore, to be imperfectly performed. It is asserted that, 
from exposure to cold or other causes, gouty inflammation is apt to subside 
suddenly, and its subsidence to be followed by grave symptoms referable 
to the stomach, heart, or nervous system. This metastatic affection, of 
which our knowledge is in every respect extremely unsatisfactory, is termed 
'retrocedent gout.' 

Gout is in general easy of diagnosis ; it may, however, under various 
circumstances, be readily confounded with rheumatism or rheumatoid 
arthritis. We do not propose to rediscuss the many pathological and clini- 
cal differences which exist between these several affections. But we may 



GOUT. 



799 



recall to mind, as being specially distinctive of gout ; its tendency to attack 
the smaller join's and lower extremities in the first instance, and mainly 
the metatarso-phalangeal joint of the great toe ; the formation of chalk- 
stones, not only in connection with the joints, but with the perichondrium 
of the cartilages of the ear and eyelids, and in other superficial positions, 
where they may be easily recognized ; and the presence of urate of soda 
in the blood. Superficial uratic concretions may be easily removed, wholly 
or in part, with the point of a lancet, and submitted to microscopic exam- 
ination, when they will be found to consist mainly of the characteristic 
needle-like crystals, more or less thickly aggregated. For the purpose of 
testing the condition of the serum of the blood, Dr. Garrod's method may 
be adopted. It is as follows : about two drachms either of the serum fur- 
nished by the blood on standing, or of the fluid raised by a blister, are to 
be placed in a flat glass dish, somewhat larger than a watch-glass, to be 
acidulated with acetic acid, and to have laid in it an ultimate fibre from a 
piece of linen cloth ; the prepared fluid is then to be allowed to stand until 
by evaporation it has been brought to the condition of a thin jelly, when, 
if there have been an undue amount of urates in the serum, the fibre will 
be found, on microscopic examination, studded with crystals of uric acid. 
To confirm the uratic character of the concretions removed from the sur- 
face of the helix, or of the crystals obtained from serum, recourse may be 
had to the murexide test, which consists in the development of a beautiful 
purple color when a small quantity of the crystalline matter is heated with 
nitric acid on a porcelain surface and then treated with ammonia. 

Pathology — It is, we believe, now generally held that, although the 
deposition of urate of soda in the joints and elsewhere furnishes the only 
trustworthy evidence of the presence of gout, this deposition, the various 
premonitory symptoms, and the almost innumerable concurrent symptoms, 
complications, and sequelae, are all traceable to the presence of urate of 
soda in the blood in undue quantity : that the disease, in fact, looked at 
from an earlier stage than the joint-affection, is to be regarded, not as a 
disease of the joints, but as an affection of the blood, a variety, as Dr. 
Murchison terms it, of 'lithasmia.' Dr. Murchison, who regards the pres- 
ence of an excess of urates in the blood as the consequence of functional 
disturbance of the liver, would naturally consider gout to have some 
such relationship to the liver as urgemic dropsy has to the kidney. Dr. 
Garrod, on the other hand, apparently inclines to the belief that the kid- 
ney, failing from some unknown cause to act efficiently in the separation 
of urates from the blood, is the organ mainly at fault. In the one point 
of view the excess of urate of soda in the blood would be due to simple 
retention, in the other to its excessive formation ; but in either case the 
deposit of this substance in the joints would be regarded as eliminative, 
and in a sense curative. Dr. Garrod further regards the inflammation of 
gouty joints as destructive of urates in the blood of the inflamed part, and 
consequently indirectly in the whole mass of the blood. Against these 
hypotheses, several important considerations may be adduced. First, as 
Dr. Garrod clearly admits, urate of soda is occasionally present in the 
blood in large quantities, and yet gout neither is present nor ensues ; 
second, although the presence of this salt in the blood seems to have been 
universally detected during the inflammatory paroxysms of acute gout, 
and during both the exacerbations and the remissions of the chronic affec- 
tion, Dr. Garrod points out expressly that it is not present during the in- 
tervals between the acute attacks, nor during that period prior to any attack 



800 DISEASES OF THE ORGANS OF LOCOMOTION. 



of inflammation in the course of which its slow deposition is taking place 
in the joints. Surely these facts are more in accordance with the hypo- 
thesis that the urate is formed in the tissues affected and thence shed into 
the blood, than with that which refers the local lesions to the precipitation 
of this salt from the already overcharged blood. We must confess, indeed, 
that our own views as to the pathalogy of gout are very nearly those which 
have recently been advocated by Dr. Ord. We are inclined to look upon 
this disease as arising from a tendency to a special form of degeneration 
in certain of the fibroid textures of the body, derived by inheritance or 
acquired by habits of life — a degeneration characterized by the excessive 
formation of urate of soda in the implicated tissues, whence, on the one 
hand, it is discharged into the blood, on the other deposited here and there, 
and especiallly in those parts (as cartilage) which are least well supplied 
with vessels and lymphatics. And we are disposed to regard the so-called 
'attacks of gout' as being in some sense accidental — predisposed to by the 
gouty deposits which have already accumulated in the part, and deter- 
mined by accidental injuries, exposure to cold, and generally any of those 
conditions which are apt to excite local inflammation. If this view be 
correct, we should expect to find a specially abundant formation of urate 
of soda in gouty tissues during the period of inflammation in them, and a 
specially abundant discharge of urates thence into the veins or lymphatics, 
or both. We know that Dr. Garrod's assertion with regard to the absence 
of urates from the serum furnished by blisters applied over the inflamed 
joints is apparently opposed to this hypothesis ; on the other hand, Dr. Ord 
quotes facts which are in its favor ; and it must be added that the experi- 
mentum cruris, namely, the chemical examination of the blood obtained 
direct from the veins leading from the inflamed parts and its comparison 
with the blood of other vessels, has not yet been performed. 

Treatment — In reference to the treatment of gout we have to consider : 
1. What should be done during the inflammatory attacks ; 2. What should 
be done during the intervening periods. 

As regards the first question, much difference of opinion prevails. 
Trousseau, following Sydenham, regards all attempts, local or general, to 
relieve pain or cut short the attack, as prejudicial. These views, how- 
ever, are not generally held, at least in their integrity ; and most physi- 
cians, we believe, would now rarely hesitate to make use of those remedies 
the efficacy of which has been proved by experience. The most valuable 
of these is colchicum, which may be given in any of the pharmacopoeial 
forms, and of which the wine may be administered in doses of from 10 to 
30 minims three times a day. Veratria has similar but less powerful anti- 
podagral properties. Quinine is another remedy, the value of which in 
largish doses, 5 or 10 grains, three times a day, has been much lauded. 
Purgatives are often of great value ; among such drugs colocynth is be- 
lieved to be especially efficacious ; and indeed the combination of quinine 
and colocynth forms the basis of some of the best known nostrums. Al- 
kalies, again, mainly the carbonates or the salts formed by their union . 
with the vegetable acids, are generally regarded as useful. The lithia- 
salts are especially recommended by Dr. Garrod in consequence of their 
solvent power over the uratic salts. When the inflammatory state of the 
joints assumes a chronic character, the above remedies may be employed, 
but with less vigor ; and at this time guaiacum and particularly iodide of 
potassium are often of great value. Generally it may be said that, during - 
the gouty paroxysms, the emunctories, above all the kidneys, should be 



RICKETS. 



801 



encouraged to free action ; the bowels kept freely open ; perspiration pro- 
moted ; and the flow of urine increased by the drinking of abundant dilu- 
ents and the use of the alkaline diuretics. Dyspeptic symptoms should 
be counteracted, for which purpose the alkalies are again serviceable ; and 
these, combined with colchicum, and either rhubarb or a vegetable bitter, 
will usually prove the most serviceable medicinal agents. As regards local 
treatment, the affected joints should be kept at perfect rest, and if neces- 
sary by mechanical means. Leeches and cold lotions are generally depre- 
cated, and warmth is not always agreeable; still the investment of the 
joints in cotton-wool, or in bran poultices, sometimes gives comfort, and 
especially the application of blisters, or the wrapping of the parts in flannel 
or cotton-wool steeped in rectified spirit and covered with oiled silk or 
gutta-percha. 

The question, however, of what should be done in the intervals to pre- 
vent the recurrence of the attacks is the more important one ; and the 
answer in general terms is not difficult. The patient should make an im- 
portant reduction in the amount of alcoholic stimulants which he is in the 
habit of taking, or, if he can do so without detriment to his digestion and 
to his general health, give them up altogether; he should refrain from ex- 
cesses in eating, and especially in eating flesh and rich articles of diet ; 
he should, in fact, while not starving himself or so restricting his choice 
of viands as to render food unpalatable, reduce his daily consumption to 
the amount which nature requires, and restrict himself to what is whole- 
some and nutritious ; he should take daily exercise, not, however, over- 
fatiguing himself or insisting on overcoming by exercise the pain or ten- 
derness of an already gout-stricken member ; he should dress himself 
warmly, and guard against unnecessary exposure to vicissitudes of tempera- 
ture ; he should avoid as far as possible all overwork of the mind as well 
as of the body, and mental anxiety; if he suffer from indigestion or other 
ailment, this should be treated. Further, tonics, such as iron and quinine, 
and periodical baths, especially the hot bath, the hot-air, vapor, or Turkish 
bath, and change of air and scene, are often of the greatest value in the 
treatment of those who suffer from chronic gout. It must, however, be 
admitted that the rules here laid down cannot, unfortunately, always be 
enforced ; and, further, that their strict enforcement will, in most cases, 
diminish only, but not eradicate the gouty tendency. 

It is in cases of this sort that recourse is constantly had to mineral 
waters. There can be no harm in taking alkaline or other waters pro- 
vided the nature of the ingredients contained in them is compatible with 
the patient's requirements. The main benefits, however, which result 
from this practice are due to change of air and scene, to the bathing, and 
to the dietetic and other restrictions which are usually enjoined and suo- 
mitted to. 



IV. RICKETS. {Rachitis.) 

Definition. — This is a disease of early childhood, characterized mainly 
by softening of the bones, with enlargement of the joint-ends of the long 
bones, enlargement of the liver and spleen, and coincident symptoms of 
general ill-health. 
51 



802 DISEASES OF THE ORGANS OF LOCOMOTION. 



Causation. — Rickets rarely shows itself prior to the sixth month after 
birth, or later than the second year, and most commonly comes on between 
the twelfth and eighteenth month. Children, however, are said to have 
been born rickety, and in rare cases the supervention of the disease has 
been delayed to the fifth or sixth year. Many causes have been assigned 
for rickets, and yet it must be confessed that a good deal of mystery still 
enshrouds its etiology. It does not appear to be hereditary in the sense 
that rickety children are the offspring of rickety parents, or even of parents 
who are scrofulous or syphilitic; it nevertheless happens that rickets is 
often the appanage of certain families of children, and in such cases (ac- 
cording to Sir W. Jenner) it is common for the younger members to suffer 
exclusively, or more severely than their elder brothers or sisters. Poverty 
and hard living would seem to exert some influence in its production ; at 
all events the children of the poorer classes are more frequent sufferers 
than those who are brought up in luxury and comfort. There is no doubt 
indeed that defective hygienic conditions generally favor it; but among 
these unsuitable feeding is probably by far the most efficient. A large 
proportion of rickety children have been brought up by hand, or have 
derived an insufficient quantity of inferior milk from inefficient nurses, 
and have at the same time been supplied with food which is more or less 
unsuitable, or even directly injurious. It is thus, probably, that delicate 
mothers are often indirectly answerable for the rickety state of their off- 
spring. The influence of improper diet in the causation of rickets seems 
proved by the experiments conducted by M. Guerin on puppies. By 
removing these animals from the mother, weaning them and feeding them 
on raw flesh (a food unsuited for them at that early age), he rendered 
them, in the course of four or five months, unmistakably rickety. Rickets 
is said to be especially common in damp and cold climates. 

Morbid anatomy and pathology The morbid changes which attend 

and characterize rickets are limited almost exclusively to the bones, liver, 
and spleen. And of these by far the most interesting and important are 
those which have their seat in the osseous system. The rickety process 
attacks all bones simultaneously, or nearly so, and in about an equal degree. 
It can, however, be best studied in the long bones. In these, the whole 
tissue tends sooner or later to become involved, but those parts in which 
growth is taking place most actively (namely the extremities and the outer 
surface) are primarily and principally affected. For the following account 
of the morbid anatomy of rickets we are mainly indebted to the investiga- 
tions of MM. Cornil and Ranvier. In the normal process by which ossifi- 
cation extends from the already ossified shaft into the cartilaginous end, 
the line of advance is even and well-defined, the cartilaginous tissue imme- 
diately bounding it (to the thickness of about one-twentieth of an inch) 
presenting a peculiar bluish transparent aspect. In this bluish cartilag- 
inous lamina the changes preliminary to ossification are going on actively. 
But it is in the layer of bone immediately subjacent to it that the earliest 
stage of actual ossification is to be recognized. In the former of these 
laminae we find the encapsuled cartilage cells becoming larger and larger 
at the expense of the surrounding hyaline tissue, and giving origin to 
daughter-cells which themselves become encapsuled, but sooner or later | 
yield large numbers of cells having the embryonic character. During this 
process, the cavities in which the cells are imbedded increase in size, and 
presently communicate, more or less freely, with one another, thus form- 
ing branching channels or alveoli full of embryonic cells, and separated 



i 



RICKETS. 



803 



from one another by areolar formed of the surviving remnants of the hya- 
line matrix. In the latter of the lamina? above referred to, earthy matter 
is being deposited in the substance of these areolae, and vessels are devel- 
oping in the alveoli from the embryonic tissue or marrow which they 
contain. A' little deeper, the concentric zones of earthy matter and stellate 
corpuscles which, by their presence within them, convert the alveoli into 
Haversian systems, may be recognized in process of formation. 

In rickets, the bluish cartilaginous lamina becomes very irregular in 
form and thickness — the chief irregularity being manifested by its under 
surface, whence numerous processes extend into the subjacent tissue, in 
which also isolated patches of cartilage may sometimes be detected. The 
chief departure from health, however, is manifested by a lamina, corres- 
ponding in position to the second of the laminae above described, which 
lies between the cartilage 'and the ossified extremity of the shaft (from 
which it is imperfectly divided), and the thickness of which varies, and 
in some cases is very considerable. This lamina has a marked resemblance 
to sponge, being, like it, both cavernous and elastic ; but it is highly vas- 
cular, and its alveoli are filled with a sanguineous pulp. Microscopic ex- 
amination shows the dependence of these abnormal appearances upon cer- 
tain striking modifications of the process of ossification. In the bluish 
cartilaginous lamina, the mother-cells give origin to daughter-cells, which 
become encapsuled ; but these, while still of large size, become encrusted 
with calcareous granules, which are also deposited in the intervening car- 
tilaginous matrix. Their further proliferation is thus to a large extent 
impeded, and they fail to regulate the subsequent process of alveolation, 
which takes place as it were without discrimination — irregular cavities 
being formed here and there by the liquefaction of the hyaline cartilage 
and the contained calcareous capsules, and irregular trabecular resulting 
from the persistence of identical tissues in the intervals between them. 
The essential departure from health seems so far to consist in calcification 
of the capsules of the daughter-cells, and in the fact that the areolae are 
formed, not of hyaline material only, but of this together with cartilage- 
cells, which are of large size, and encrusted with earthy salts. In the 
spongy tissue beneath the same process goes on ; the alveoli (instead of 
getting smaller, as they do in healthy ossification, from the formation of 
concentric laminae) grow larger and larger, the areolae undergoing corres- 
ponding rarefaction and destruction, and becoming at the same time more 
and more calcareous. The medulla which occupies the cavities is richly 
provided with large delicate-walled vessels, and an abundance of ordinary 
granulation or embryonic tissue. The morbid processes which go on be- 
tween the shaft and the periosteum are (allowing for the anatomical dif- 
ferences between cartilage and periosteum) identical with those just de- 
scribed. The periosteum in the normal condition may be readily stripped 
as a membranous lamina from the surface beneath. In rickets a soft 
spongy formation, of variable and often considerable thickness, intervenes 
between them. This consists of refractive trabecular, formed partly of 
intercellular substance, partly of connective-tissue corpuscles, and infil- 
trated to a greater or less extent with earthy matter ; and of intercommu- 
nicating medullary spaces filled with embryonic tissue and new-formed 
bloodvessels. It is obvious that the areolae or trabecular, whether formed 
from cartilage at the epiphysal extremities of the bone, or from periosteum 
at its surface, and whether infiltrated with earthy matter or not, are con- 
tinuous with the solid framework of the completely formed bone-tissue 



804 



DISEASES OF THE ORGANS OF LOCOMOTION. 



underneath ; and that the embryonic or granulation tissue which fills their 
alveoli is continuous with the normal medullary matter occupying the 
Haversian canals, medullary spaces, and central cavity of the bone. And 
it may be added that, if the rickety condition persist and extend, not only 
do the alveoli of the new-formed tissue enlarge at the expense of the tra- 
becule between them, but the medullary tissue of the normal bone-cavities 
gradually acquires the embryonic character, the bone-tissue melts away 
around it, the Haversian canals and all other spaces consequently undergo 
enlargement, and general rarefaction ensues. Sir W. Jenner observes that 
the bones of healthy children yield about 37 per cent, of organic and 63 of 
earthy matter, whereas those of rickety children sometimes yield as much 
as 79 per cent, of organic and only 21 of earthy matter. 

The general consequences of rickets are that the bones thicken (a change 
which is especially evident in the joint-ends of the long bones and in the 
edges of the flat bones of the skull) and become soft, and consequently 
liable to bend, or to break with the so-called 'green-stick' fracture. The 
enlargements are most obvious at the wrist and ankle joints, and at the 
elbows and knees ; they are frequently also well shown at the junctions of 
the ribs with the costal cartilages, along the lines of the cranial sutures, 
and elsewhere where bones are in relation with epiphysal cartilages. The 
curvature of bones comes on somewhat later than their manifest thicken- 
ing, and usually proceeds from the lower part of the skeleton upwards. 
Its direction is determined partly by that of the normal curvatures of the 
bones and partly by the direction and force of the mechanical influences 
which act upon them. The tibiae and fibulae usually bulge forwards and 
outwards, and the femora follow suit ; when, however, the rickety condi- 
tion appears late, the bending of the legs is often in the opposite direction, 
and the child becomes knock-kneed. The radius and ulna for the most 
part acquire a curve with the convexity facing backwards ; but the shape 
of the humerus is often determined by the attachment of the deltoid. The 
shoulders get narrowed by the shortening of the clavicles due to exagger- 
ation of their natural curves. The back becomes bent in the same sense, 
and often more or less twisted : by increase of the cervical curve the head 
tends to be thrown backwards, and the face to be directed upwards and 
forwards ; exaggeration of the dorsal and lumbar curves is often attended 
with lateral deviation connected with rotation of the bodies of the verte- 
brae upon their axes. In children who have not yet walked the lumbar 
curvature is lost in that of the dorsal region, and both combine to form 
the segment of a circle with the concavity looking forwards. The shape 
of the chest in rachitic children becomes remarkably modified ; the ribs 
sink in laterally, especially from about the third to the ninth, so that the 
transverse diameter is diminished in this situation, while the anteroposte- 
rior is correspondingly augmented, and the sternum thrown forwards. 
There is usually also in the same part of the chest a well-marked vertical 
groove running down on either side, just external to the junctions of the 
ribs and cartilages. The form of the upper part of the chest, however, 
is slightly or not at all altered ; while the lower part, owing to the presence 
of the liver, spleen and other abdominal viscera, again expands, and its 
shape is pretty nearly normal. The changes which take place in the form 
of the pelvis are of great importance. The bones of the upper part get 
flattened and expanded by the pressure of the abdominal viscera upon 
them ; but the weight of the spine above throws the sacrum forwards, and 
the pressure of the femora below causes an approximation of those parts 



RICKETS. 



805 



of the pelvis which bound the acetabula ; and the pelvic cavity conse- 
quently becomes contracted, and tends to assume a triangular form on 
transverse section. But the relative effects of these and other agencies are 
largely modified in different cases by a variety of circumstances, such as 
age, and the possession and use of the powers of walking, crawling, or 
sitting. The bones of the head and face share in the tendency to deformity. 
The fontanelles are slow to close, remaining open up to and beyond the 
second year ; the head becomes large, flat on the top, elongated from be- 
fore backwards, with projecting forehead, and unusual prominence of the 
frontal and parietal eminences. The teeth are late in appearing ; and in- 
deed if none have been cut by the age of nine months, it is a reason for 
at all events suspecting the presence of rickets. The teeth, moreover, are 
specially apt to decay and become loose. It will of course be understood 
that the deformities of the skeleton in rickety children are liable to innu- 
merable variations from the types which have been enumerated ; that in a 
large number of cases they never become serious, and are probably con- 
fined to the bones of the legs and perhaps some few others; while in some 
cases they assume such extreme proportions that they are not only a source 
of distress and misery, but are incompatible with the performance of some 
of the normal functions of life, or even with the maintenance of life. 

After a time, which varies in different cases, the rickety condition 
ceases, and the bones regain their earthy elements and their strength. 
The bone tissue, indeed, gets unnaturally strong and dense. In some 
cases slight degrees of curvature slowly disappear in the progress of 
growth ; more frequently, however, they are persistent, and there is more 
or less of permanent deformity. 

Dr. Dickinson's observations seem to show : that a morbid process, in 
some respects like that in the bones, goes on in the kidneys and lymphatic 
glands, and especially in the liver and spleen of rickety children ; and that 
these organs become enlarged and indurated, and the seat partly of inter- 
stitial development of fibroid tissue, partly of overgrowth of the glandular 
elements. The changes are transitory, and are accompanied by a deficiency 
of the earthy salts. They are quite distinct from amyloid or lardaceous 
degeneration. 

Whatever the exciting cause of rickets may be, and however it acts, 
there can be little doubt that the morbid processes to which it gives rise 
in the several viscera which have been enumerated, and in the bones, 
have a close affinity with those of general subacute or chronic inflamma- 
tion, and that the main incidents in them are an irritative overgrowth of 
the implicated tissues, and a modification or perversion of their normal 
nutrition. 

Symptoms and progress In giving an account of the clinical phe- 
nomena of rickets, it is customary to enumerate a long series of precursory 
symptoms, the occurrence of which not only should excite suspicion of the 
impending danger, but is commonly regarded as a proof that rickets is the 
outcome of some more or less long-continued cachexia or dyscrasia. The 
constitutional origin of the malady can scarcely be denied ; but it is cer- 
tain that it must always have made some considerable progress before the 
deformity of the joint-ends of the long bones or of the chest, and the 
bending of limbs, become obvious, and that many, therefore, of the pre- 
cursory symptoms belong properly to the earlier stages of the rickety pro- 
cess. Among these must probably be included catarrhal affections of the 
thoracic viscera, and gastro-intestinal disturbance. But by far the most 



806 



DISEASES OF THE ORGANS OF LOCOMOTION. 



important and characteristic are : first a febrile condition, manifested by 
restlessness at night or during the hours devoted to sleep, intolerance of 
the bedclothes, which the infant continually throws off, and profuse per- 
spiration, mainly limited to the head and upper parts of the body; and, 
second, general tenderness or soreness, due doubtless to general implica- 
tion of the bones, and indicated by a gradually increasing unwillingness 
or fear to move or be moved, and a loss of enjoyment in the caresses and 
dancings which form so large a part of a healthy infant's life and happi- 
ness. The first distinct evidence, however, that the bones are undergoing 
serious change of structure is usually afforded by the enlargement of the 
lower extremities of the radius and ulna, and by the simultaneous or 
shortly subsequent enlargement of the corresponding portions of the tibia 
and fibula, and of the knee- and elbow-joints. If the affection still pro- 
ceeds, the shafts of the long bones and the spine acquire the alterations of 
form which have already been adverted to : the ribs fall in at the sides, 
the sternum protrudes anteriorly, and the pigeon-breasted condition results, 
in association with which the knob-like enlargement of the anterior ex- 
tremities of the ribs on either side produces that characteristic appearance 
to which the name of' the ' rickety necklace' or 1 chaplet' has been ap- 
plied ; the pelvis gets distorted ; and the bones of the head become affected, 
mainly, as has been pointed out, by thickening of their edges, protrusion 
of the parietal and frontal eminences, and unusual persistency of the fon- 
tanelles. But while all these deforming processes are going on with more 
or less uniformity and rapidity, the various symptoms which marked the 
beginning of the disease usually undergo aggravation ; the fever becomes 
more intense, the pulse accelerated, the heat of skin augmented, the noc- 
turnal perspirations more profuse, and the general tenderness more marked. 
Actual pain, indeed, often supervenes ; and the fear or inability to move 
and the dread of being touched become much more apparent. In connec- 
tion with these phenomena the appetite fails, there are thirst and irregu- 
larity of bowels, the urine is copious and contains a superabundance of 
phosphates, and the child undergoes rapid emaciation with disproportionate 
wasting and feebleness of the voluntary muscles ; he assumes an anaemic 
or pallid, sad, anxious, wan aspect, and takes no interest in what is going 
on about him. During all this time the abdomen becomes relatively large, 
and the liver and spleen will probably be found to be distinctly hypertro- 
phied ; indeed, the enlargement of these organs is sometimes one of the 
earliest indications that the child is rachitic. Ascites is sometimes a con- 
sequence of the hepatic affection. The influence of rickets on dentition 
has already been fully considered. According to MM. Rilliet and Barthez, 
whose opinions are confirmed by those of Dr. H. Roger, a blowing sound 
is so commonly audible over the cranial sutures of rachitic children that 
it may almost be regarded as diagnostic of the affection. 

[Under the name of craniotabes, Elsasser has described certain changes 
in the bones of the cranium, which, although not alluded to by Sir William 
Jenner, are regarded by Virchow as among the unquestionable conse- 
quences of the rachitic diathesis. This view of their nature was accepted 
by the late Dr. John S. Parry, of Philadelphia, from whose masterly essay 
on Rickets the following condensed description is taken. Craniotabes is 
one of the earliest alterations of the disease, the occipital bone becoming 
thin, and occasionally even perforated, so that nothing separates the brain 
from the inner surface of the scalp but the dura mater and pericranium, 
which are in contact. In many cases this condition is found only in this 



RICKETS. 



807 



bone, but in patients who have the disease in a severe form, the posterior 
margins of the parietal, and sometimes even the squamous portions of 
the temporal bones, may be involved. The protuberances of the occipital 
and parietal bones are never diseased, the perforations, which in one of 
Dr. Parry's cases were twenty-five in number, being usually situated near 
the sutural margins of these bones, or in those parts of them which are 
developed from membrane, while on the other hand, those which are pro- 
duced from cartilage always, so far as is known, remain healthy. In order 
to detect craniotabes, the physician should take a position immediately 
before the child, and placing the heels of his hands upon the temples, 
carefully examine the upper portion of the occipital and the posterior por- 
tions of the parietal bones with his fingers. If perforations exist, they 
will be easily detected, generally just within the sutural margins. This 
examination should be made very carefully, as, according to Niemeyer, 
pressure upon these soft spots has occasioned convulsions. The various 
nervous disorders so frequently met with in rachitic children, as, for in- 
stance, laryngismus stridulus, are attributed by writers to this yielding 
condition of the skull, readily permitting the occurrence of pressure upon 
the brain. These perforations are always preceded by thickening and 
softening of the bone, and are produced by the pressure of the brain on 
one side, and of the pillow on the other. Thickening of the frontal bone, 
followed by permanent deformity, is also a frequent result of this disease. 

The head very frequently in this disease loses its natural rounded out- 
line and assumes a square one, which is in accordance with an important 
general law which governs the changes in the rachitic skeleton, and which 
Dr. Parry formulated as follows. Aside from distortions by bending or 
twisting, rachitic bones are characterized by an arrest of development, 
with retention of the foetal type.] 

When rickets proves fatal, it is usually either by gradual asthenia con- 
nected with the advance of the disease and impairment of the digestive 
functions, or by thoracic complications, such as collapse of the lung-tissue, 
lobular pneumonia, or bronchitis — the accession as well as the gravity of 
which are largely dependent on the weakness, deformity, and consequent 
inefficiency of the thoracic walls. Other causes of death in rickety children 
are laryngismus stridulus, convulsions, and chronic hydrocephalus. The 
duration of rickets commonly ranges between six and twelve months, at 
the end of which time the constitutional symptoms and those indicative of 
osseous inflammation subside. 

Persons who have suffered from rickets in infancy not unfrequently 
acquire great strength of limb (muscle and bone), but they usually remain 
of low stature ; and the deformities which take place at the time of their 
malady only too commonly persist ; while some (more especially those of 
the chest and pelvis) not unfrequently entail serious misery and danger in 
after-life. 

In concluding this brief account of the symptoms of rickets, it is well to 
draw attention to the fact that the disease may be present in a slight de- 
gree — sufficient to cause manifest thickening of the wrists and ankles, and 
even bending of the tibiaa and thoracic walls — in children who maintain 
their vivacity and the aspect of almost perfect health. 

Treatment — It might be supposed, from the fact of the disappearance of 
phosphate of lime from the bones, that the administration of phosphate of 
lime is indicated in the treatment of rickets. Experience has not, how- 
ever, confirmed this view, nor indeed does a correct interpretation of the 



808 



DISEASES OF THE ORGANS OF LOCOMOTION. 



pathological phenomena of the disease give it any sanction. The best 
medicinal remedies are tonics, such as iron and cinchona, and, above all, 
cod-liver oil. But these are valueless without the most careful attention 
to diet and hygiene. The diet should be at once nutritious, sufficiently 
abundant, and adapted to the age and circumstances of the child. For the 
young infant nothing can be more suitable than the healthy breast, or fail- 
ing that, asses' milk, or else cows' milk, or preserved Swiss milk, properly 
diluted, and mixed, it may be, with a certain proportion of biscuit powder. 
At a later age a moderate quantity of well-cooked meat, comprised in a 
dietary which combines all the other essential elements of food, namely, 
sugar, starch, and fat, and composed therefore largely of milk and bread 
and butter, should be administered. The child should be warmly clad, 
should occupy an airy but sufficiently warm room, be regularly bathed and 
well rubbed afterwards, and taken out habitually into the open air. 
Change of air, and especially residence on the sea-coast, are often of essen- 
tial service. But, in addition to the above measures, it may be desirable 
to treat the symptoms which are so apt to accompany rickets: to improve 
the condition of the stomach, to regulate the action of the bowels, to reduce 
fever, and to combat pulmonary and other complications. And especially 
it is of paramount importance to prevent as far as we possibly can the 
supervention of deformity. To this end, our measures must be regulated 
by the age and peculiarities of the patient. It is impossible to go into 
detail without becoming unsuitably diffuse. We may, however, point out 
that the child should lie on a soft well-made feather bed ; that if it be quite 
young, it should not be allowed to sit up ; and that if older (and the limbs 
give evidence of bending), it should be prevented from walking, and per- 
haps even from crawling. Mechanical appliances may be necessary to 
restrain undue locomotion. 



V. MOLLITIES OSSIUM. (Osteo-malacia.) 

Definition and causation. — This affection has in many respects a close 
resemblance to rickets. It occurs, however, not in children, but in adults. 
It has been recognized, indeed, only in svomen, and for the most part in 
women who are bearing children. 

Morbid anatomy and pathology Mollities dssium is characterized ana- 
tomically by progressive softening of the bones, sometimes of those of the 
whole skeleton, occasionally of a limited number only. The minute changes 
appear to consist mainly in a progressive decalcification of the bony tissue, 
commencing from the Haversian canals and medullary spaces, and gradu- 
ally involving the successive laminae of bone which surround them, until 
finally decalcification is complete. A sharp line generally marks the limit 
of the morbid process, the bone external to it being still normal, whilst 
that between it and the canal or cavity is converted into a kind of fibroid 
tissue, in which the bone-corpuscles are scarcely distinguishable. At a 
later period the portions of tissue first affected soften and liquefy. Attend- 
ing these changes the smaller vessels become dilated, and the contents of 
the various cavities red and pulpy. The enfeebled bones are liable to all 
those bendings and imperfect fractures which also characterize rickety 
bones ; but, owing to the long duration of the malady and the extent to 



MOLLITIES OSSIUM. 



809 



which softening takes place, the deformity which ensues is usually of the 
most aggravated kind and pretty universal. Trousseau maintains that 
mollities ossium is identical with rickets, allowance being made for differ- 
ence of age and for the fact that the active processes of growth have ceased 
when osteo-malacia makes its appearance. The anatomical details, how- 
ever, of the two processes are manifestly different. It is supposed by Rind- 
fleisch and some others that the decalcification is due to the action of some 
acid (carbonic or lactic) contained in the blood. The appearances are, no 
doubt, much like those which might be thus caused. There is no direct 
evidence, however, to support this view ; and indeed Virchow has ascer- 
tained the existence of a strong alkaline reaction in the gelatine yielded by 
fresh bones affected with this disease. 

Symptoms and progress. — The symptoms of osteo-malacia, like those of 
rickets, are often very insidious ; and the disease may first reveal its pres- 
ence by the occurrence of deformity and fracture of bones. Its progress, 
however, is usually attended, even from the beginning, with febrile dis- 
turbance and copious perspirations, and with tenderness and pain in the 
course of the affected bones. The pains are, in the first instance, vague 
and wandering, and of a shooting character. But they gradually become 
more or less intense; affect not only the limbs, but the trunk, heal, and 
face ; and are greatly aggravated by movement or pressure. They are 
often most severe in the joint-ends of long bones, and in the epiphysal ends 
of most bones. They may easily be mistaken at first for rheumatic or 
neuralgic pains. The urine contains an excess of phosphate of lime. 

The progress of osteo-malacia is chronic ; cases have been met with in 
which the disease has been prolonged for fourteen or fifteen years and 
upwards. Death usually takes place, however, at a much earlier date, 
and is generally due immediately to interference with the respiratory or 
circulatory functions. Recovery very rarely takes place, and never with- 
out persistent deformity. Trousseau has recorded a case or two of this 
kind. 

Treatment — No distinction need be drawn between the treatment of 
osteo-malacia and that of rickets. It was under the use of cod-liver oil 
that Trousseau's cases recovered. 



810 DISEASES OF THE NERVOUS SYSTEM. 



CHAP TEE VIII. 

DISEASES OF THE NERVOUS SYSTEM. 

I. INTRODUCTORY REMARKS. 
A. Anatomy and Physiology. 

The nervous system comprises the cerebrum and cerebellum, with the 
various ganglia and commissures which belong to these bodies, the medulla 
oblongata, the spinal cord, the sympathetic ganglia, and the nerves which, 
springing from these several sources, are distributed throughout the organ- 
ism. With the central organs are associated as important elements the 
various membranes and other structures which serve for their support and 
protection, and the arteries and veins which minister to their nutrition and 
functional activity. 

1. Membranes of brain and cord The cranial dura mater is a thick, 

dense, inelastic, fibrous membrane, which by its outer surface adheres 
firmly to the bones of the skull, by its inner surface, which is smooth and 
polished, constitutes the parietal limit of the arachnoid cavity. It also 
forms certain septa, needless to specify, which intervene between the cere- 
brum and cerebellum and their respective hemispheres. At the foramina 
for the exit of nerves at the base of the skull the dura mater becomes 
continuous on the one hand with the pericranium, on the other with the 
nerve-sheaths. The spinal dura mater, which, like the cranial, is dense, 
thick, and elastic, is prolonged in the form of a loose bag from the margins 
of the foramen magnum, to which it is adherent, to the first or second | 
sacral vertebra, where, blending with the filum terminate of the cord, it 
is continued onwards therewith to the lower end of the sacral canal. The ; 
spinal dura mater is separated on all sides from the bony cavity in which 
it lies by fat and areolar tissue. Its internal surface is smooth and polished, ! 
and presents along either side a double series of orifices of which each 
contiguous pair gives exit to the anterior and posterior roots of one of the 
spinal nerves. The dura mater is continued on each nerve as a tubular 
prolongation, within which the ganglion of the posterior root is contained. 
It then blends with the sheath of the nerve and becomes connected by 
fibrous processes with the margins of the intervertebral foramen. 

The arachnoid cavity is usually regarded as a serous cavity. It occu- 
pies the interval between the dura mater, on the one hand, and the general 
surface of the brain and cord on the other, being perfectly continuous 
throughout. Its outer limit is represented by the smooth inner aspect of 
the dura mater ; its inner limit is formed by a delicate transparent mem- 
brane which lies loosely upon the surface of the central organs, never 
dipping into the sulci, and lying especially loosely upon the parts situated 
at the base of the brain, and upon the spinal cord. The inner and outer 
aspects become continuous by means of tubular prolongations wherever 



ANATOMY AND PHYSIOLOGY. 



811 



nerves or vessels pass from the protective organs without to the central 
nervous organs within. 

The pia mater is the vascular membrane which closely invests the outer 
surface of the brain and cord, following all its inequalities. It is continu- 
ous by its applied surface with the connective web and vascular network 
which pervade the substance of the subjacent organs, and the neurilemma 
of the nerves appears to be derived from it. The pia mater within the 
skull is delicate and highly vascular, dips to the bottom of all sulci, and 
accurately fits the complicated arrangement of processes and depressions 
which exist at the base of the brain. It dips also into the great trans- 
verse fissure of the brain and into the somewhat similar fissure existing 
behind between the medulla oblongata and the cerebellum — forming in 
either situation a reduplication, the free margins of which are wrinkled 
and folded, and constitute the bodies known as the choroid plexuses. The 
pia mater of the cord is much thicker, denser, and less vascular than that 
of the brain, forms in front a duplicature which dips to the bottom of the 
anterior furrow, and behind a thin vertical septum which occupies the 
posterior furrow. 

The interval which exists between the pia mater and the visceral lamina 
of the arachnoid is known as the subarachnoid space; it is crossed by 
numerous delicate fibrous bands, and in the spinal canal on either side by 
the ligamentum denticulatum and behind by an incomplete vertical sep- 
tum. It is the seat of the subarachnoid fluid which constitutes the great 
bulk of the cerebro-spinal fluid. 

2. Ventricles of brain and cord — The existence of the ventricles of 
the brain and cord (excepting the fifth) as distinct cavities is due in some 
sense to the failure already referred to of the pia mater at the great trans- 
verse fissure of the brain and at the posterior part of the fourth ventricle 
to follow the various diverticula or involutions which take their origin in 
these situations. The system of ventricles comprises : the lateral ventri- 
cles, which are continuous with one another and with the third ventricle 
in the interval, into which the velum interpositum extends, between the 
fornix above and the optic thalami below ; the third ventricle, which com- 
municates by means of the iter with the fourth ventricle ; the fourth ven- 
tricle ; and the central canal of the cord which commences above at the 
calamus scriptorius or posterior extremity of the fourth ventricle. The 
nervous boundaries of the ventricles are covered with a delicate mem- 
brane which is continuous with the neuroglia or connective web permeat- 
ing the substance of the subjacent organs, is identical in structure with it, 
and is furnished with an epithelium. The ventricles form a continuous 
system, and have no communication with other cavities or spaces, except- 
ing as was pointed out by Majendie, with the subarachnoid space through 
a small opening situated at the lower extremity of the fourth ventricle. 

3. Cerebral hemispheres — The cerebrum consists of two hemispheres, 
separated the one from the other above by the great longitudinal fissure, 
and united below mainly by means of the commissural fibres of the corpus 
callosum, by the fornix and certain other structures which need not be 
specified. It is composed of white and gray matter, of which the one 
forms a comparatively thin lamina on the surface, while the other makes 
up the great bulk of its mass. The surface of the organ, and with it of 
course the gray matter, is arranged in folds or convolutions, separated by 
fissures or sulci, the more important of both of which present a tolerably 
definite and regular arrangement. The superficial gray matter is doubt- 



812 



DISEASES OF THE NERVOUS SYSTEM. 



less the seat of the intellectual and emotional functions and the primary 
source of those various combined muscular actions which accompany and 
reveal their operation. The study of the convolutions is, therefore, a mat- 
ter of interest, especially in connection with the localization of function, 
on which subject important light has been thrown by modern pathology 
and recent experimental inquiries. We proceed to describe so much of 
the topography of the cerebral surface as bears directly on this subject. 

a. Fissures — The fissure of Sylvius (Fig. 3 and 10 d) commences on 
the base of the brain at the locus perforatus anticus, and, separating the 
middle from the anterior cerebral lobe, passes directly outwards until it 
reaches the lateral aspect of the hemisphere. Here it divides into two 
branches : an anterior short branch, which proceeds upwards and forwards, 
and a posterior long branch, which courses nearly horizontally backwards 
upon the outer surface, dividing the temporo-sphenoidal lobe below from 
the parietal lobe above. The fissure of Rolando, or sulcus centralis (Fig. 

3 and 6 c), commencing above at the great longitudinal fissure a little be- 
hind the vertex, runs downwards and forwards over the outer surface of 
the hemisphere to near the point of bifurcation of the Sylvian fissure, 
separating the frontal lobe in front from the parietal lobe behind. The inter 
parietal fissure (Fig. 3 and 6 e), originating in the angle contained be- 
tween the fissure of Rolando and the posterior Sylvian branch, passes 
irregularly backwards towards the parietooccipital fissure. The parallel, 
or first temporo-sphenoidal fissure (Fig. 3 /*), running parallel to but be- 
low the posterior Sylvian branch, turns up behind its posterior extremity, 
and there loses itself in a group of convolutions which are limited above 
and behind by the posterior part of the inter-parietal fissure, and are known 
by the name of the gyrus angularis, or pli courbe. On the inner aspect 
of each hemisphere there are four fissures which call for special notice : — 
the first is the fronto-parietal, or calloso-marginal (Fig. 4 which, 
commencing in front, runs backwards parallel with the corpus callosum, 
forming the upper limit of the gyrus fornicatus, until having arrived near 
the posterior edge of the corpus callosum, it turns up to reach the upper 
margin of the hemisphere a little behind the upper termination of the 
fissure of Rolando ; the second is the vertical or parieto-occipital (Fig. 

4 g), which separates the occipital from the parietal lobe, and, commencing 
above on a level with the posterior extremity of the parallel sulcus, runs 
downwards and forwards to unite at an acute angle with (third) the calcarine 
fissure (Fig. 4 /), which is nearly horizontal in position and corresponds 
to the hippocampus minor ; the last is the hippocampal fissure (Fig. 4 m), 
which runs round the crus cerebri, and indicates the course of the hippo- 
campus major. 

b. Convolutions In front of the fissure of Rolando, and following its 

course from below upwards, runs the ascending frontal, or anterior parie- 
tal convolution (Fig. 3 and 6 d), and from the anterior aspect of this are 
given off in succession from above downwards the first, second, and third 
frontal convolutions (Fig. 3 and 6 a b c). The first of these runs parallel 
to the longitudinal fissure, and forms, indeed, the marginal convolution 
(Fig. 4 a) of that fissure ; the second follows the same course as the first, 
but lies external to it ; and the third, still more external, by its posterior 
part forms the upper and anterior boundary of the anterior branch of the 
fissure of Sylvius, and by its anterior part separates the second convolution 
above from the external orbital convolution below. The third frontal con- 
volution of the left side is also called Broca's convolution. The orbital 



ANATOMY AND PHYSIOLOGY. 



813 



convolutions occupy that portion of the under surface of the anterior cere- 
bral lobe which lies upon the floor of the skull. Parallel to the ascending 
frontal convolution, and separated from it by the fissure of Rolando, 
courses the ascending parietal convolution (Fig. 3 and 6 e e), from the 



Fig. 3. 




Lateral view of brain, showing principal convolutions and fissures. 



Fig. 4. 




Inner surface of hemisphere, showing principal convolutions and fissures, and Ferrier's centres 
of touch (xiii.), and of smell and taste (xiv.). 
The several letters in the above figures, and also in figures 5, 6, 8, 9, and 10, refer to the same 

parts. 

Fissures — a, superior frontal ; &, inferior frontal ; c, fissure of Eolando ; d, fissure of Sylvius; 
e, inter-parietal ; /, fronto-parietal ; g, parietooccipital ; h, first temporo-sphenoidal ; i, second 
ditto ; j, third or inferior ditto ; k. occipitotemporal ; I, calcarine ; m, hippocampal 

Convolutions: — A, superior, or first frontal ; b, second ditto; c, third ditto ; d, ascending frontal, 
or anterior parietal ; e, ascending parietal ; F, superior parietal ; p y , prsecuneus ; a, supra mar- 
ginal ; g /5 gyrus angularis, or pli courbe ; h, first temporo-sphenoidal; i, second ditto; J, third 
ditto ; K, fusiform lobule ; l, lingual lobule ; m, gyrus fornicatus ; M /; gyrus hippocampi ; m //? un- 
cus gyri fornicati, or subicitlum cornu Ammonis ; n, cuneus. 

posterior and outer margin of which two secondary convolutions, separated 
from one another by the inter-parietal sulcus, pass nearly directly back- 
wards : the inner and upper one, the superior parietal convolution (Fig. 
3 and 6 f), forming the margin of the longitudinal fissure in this situation, 



814 



DISEASES OF THE NERVOUS SYSTEM. 



and ending behind at the parietooccipital fissure ; the outer and lower one, 
or gyrus supra-rnarginalis (Fig. 8 and 6 g), lying, at its anterior ex- 
tremity, mainly between the inter-parietal sulcus and the posterior branch 
of the fissure of Sylvius, and further back between the inter-parietal sulcus 
and the posterior extremities of the Sylvian and first temporo-sphenoidal 
fissures. In the latter part of its course it is considerably curved, and 
receives the name of gyrus angularis, or pli courbe (Fig. 3 and 6 g). 
There are three temporo-sphenoidal convolutions passing nearly horizon- 
tally backwards from the anterior part of the temporo-sphenoidal lobe ; 
the first (Fig. 3 h) is situated between the posterior branch of the Sylvian 
fissure above and the first temporo-sphenoidal fissure below ; the second 
(Fig. 3 i) lies below the first temporo-sphenoidal fissure; the third is 
lower down, but parallel to the others. At the bottom of the fissure of 
Sylvius, at its point of bifurcation, and concealed by the overlying convo- 
lutions, lies the island of Reil, the gray matter of which is in close ana- 
tomical relation in front with that of the posterior part of the third frontal 
convolution, behind with that of the first temporal. On the internal 
aspect of the hemisphere, amongst other convolutions, may be observed 
the gyrus fornicatus (Fig. 8 m), which, commencing in front beneath the 
genu of the corpus callosum, runs backwards over this body between it 
and the calloso-marginal fissure, then turns round its posterior extremity, 
being continued downwards and forwards under the name of the gyrus 
hippocampi, or uncinate convolution (Fig. 8 and 10 first between the 
hippocampal and calcarine fissures, and thence nearly horizontally forwards 
until it reaches the internal extremity of the fissure of Sylvius, where it 
forms the uncus gyri for nicati, or subiculum cornu Ammonis (Fig. 8 and 
10 For an account of the remaining convolutions, to some of which 

we may subsequently allude incidentally, we must refer to anatomical 
works. 

In connection with the subject of the convolutions it may be observed 
that M. Betz has recently shown that the surface of the cerebrum may be 
divided by microscopic peculiarities into regions, of which the anterior, 
limited by and including the ascending parietal convolution, is character- 
ized by containing, in greater or less abundance, giant-cells resembling 
those of the anterior cornua of the spinal cord, the posterior by an almost 
total absence of such cells. 

4. Ganglia at base of brain. — Excepting the commissural fibres of the 
corpus callosum and fornix, and certain other commissures, which need i 
not be enumerated, all the nerve-fibres from the gray matter of the convo- 
lutions converge to the group of ganglia situated at the base of the brain, 
namely, the corpora striata and the optic thalami, together with the cor- 
pora geniculata and corpora quadrigemina, and are thence continued 
(directly or indirectly) either through the superior cerebellar peduncles to 
the cerebellum or along the crura cerebri to the medulla oblongata. 

Each striated body comprises three nuclei, separated from one another 
by white fibres. The first of these is the caudate nucleus, and is that por- 
tion of the body which is visible in the lateral ventricle. The second is 
the lenticular nucleus, which is placed in part external to and below the 
caudate nucleus, in part external to and below the optic thalamus: being 
separated from these bodies by a layer of white fibres, which forms the 
internal capsule, and on the outer side from the gray matter of the island 
of Reil by a similar white lamina, which is known as the external capsule. 
Imbedded in this last is the third or tceniceform nucleus or claustrum, 



ANATOMY AND PHYSIOLOGY. 



815 



which forms an exceedingly thin plate. The cerebral fibres which enter 
these nuclei and occupy the intervals between them come from all parts of 
the cerebral surface, but mainly from the anterior half ; and those which 
emerge from them below pass mainly downwards and backwards to form 
the under portion or crust of the corresponding cerebral peduncle within 
which they become connected with an additional ganglion of the same 
system, namely, the locus niger. The further destination of the crust is 
twofold ; it sinks into the anterior and upper edge of the pons, and there 
divides into two portions ; of which one, according to Meynert, crosses 
among the anterior fibres of the pons, and passes with these to the oppo- 
site half of the cerebellum, thus decussating with its fellow ; while the 
other emerges from the posterior border of the pons as the anterior pyra- 
mid, which also decussates with its fellow, and is prolonged mainly to form 
the lateral column of the opposite side of the cord. 

The optic thalamic corpora geniculata and corpora quadrigemina also 
derive fibres from nearly all parts of the cerebral surface, though mainly 
probably from the posterior and lateral portions ; and, resting by their 
under surface upon the cerebral peduncles, are more or less directly con- 
tinuous with their upper half or the tegmentum. This, which includes 
within it the red nucleus, divides like the crust into two portions. One of 
these continues backwards as the processus e cerebello ad testes and valve 
of Vieussens to form the superior peduncles of the cerebellum ; and the 
fibres which constitute it for the most part decussate anteriorly to the pos- 
terior limit of the testes, and so reach the opposite sides of the cerebellum. 
The other continues downwards, in the substance of the pons and on the 
floor of the fourth ventricle, to become continuous mainly with the sensory 
tracts of the medulla oblongata and cord. 

5. Cerebellum and its peduncles So little is known comparatively of 

the specific functions of different parts of the cerebellum that it is needless 
to consider here either its general form and arrangement or the names 
which have been given to its separate lobes and lobules. It may, how- 
ever, be pointed out that, in addition to its superficial gray investment, it 
contains imbedded in its white medulla in the first place two ganglia (one 
on either side), the corpora dentata, and in the next place two other gray 
nuclei, the roof nuclei of Stilling, which lie below the central lobule of 
the superior vermiform process. 

The cerebellum presents three pairs of peduncles or groups of white 
fibres, of which one comes from the cerebrum, one from the medulla ob- 
longata, and the other is mainly transversely commissural. The first pair 
or the superior peduncles come almost exclusively from the tegmentum of 
the cerebral peduncles, comprise the processus e cerebello ad testes with 
the intermediate valve of Vieussens, and pass into the corpora dentata and 
thence to the convolutions. The second pair or the middle peduncles are 
constituted mainly by the transverse fibres which form the great bulk of 
the pons Varolii, but comprise the cerebellar fibres derived from the crust 
of the cerebral peduncles ; of these the more internal pass into the roof 
nuclei, but the outermost, accompanied by the restiform bodies, reach 
the surface of the cerebellum without the intermediation of either of these 
ganglia. The third pair or the inferior peduncles are the restiform 
bodies. 

It will thus be seen that the most direct, if not the only, communication 
between the hemispheres of the cerebrum and those of the cerebellum is 
effected by means of fibres which, taking their origin in the cerebral gan- 



816 



DISEASES OF THE NERVOUS SYSTEM. 



glia, pass backwards and lose themselves probably in the ganglia imbedded 
in the white substance of the cerebellum ; that of these some are derived 
from the crust, some from the tegmentum of the cruri cerebri, and that all, 
according to Meynert, decussate in the course of their passage. It will 
also be gathered that both the cerebrum and the cerebellum send down 
strands of fibres to take part in the formation of the medulla oblongata. 
Those from the brain are continued from both layers of the crura cerebri ; 
those from the cerebellum are the restiform bodies. 

6. Spinal cord — Before speaking further of the medulla oblongata it 
will be well to describe the spinal cord. This, which extends, in the 
adult, from the foramen magnum above to the lower part of the first lumbar 
vertebra below, presents an anterior and a posterior median fissure, and, on 
either side, two lateral furrows, which correspond to the successive points 
of emergence of the anterior and posterior roots. It is thus divided super- 
ficially, on each side, into posterior, lateral, and anterior columns. But, 
in addition to these, a slender median column, most obvious in the upper 
part of the cord, may be observed running along the edge of the posterior 
median fissure. On transverse section the gray matter of the cord will be 
found to occupy its central part, the white its periphery. The gray matter 
is arranged in the form of two lateral crescents, placed back to back, and 
united with one another in the middle by a transverse commissure, which 
crosses the narrow interval between the bottoms of the anterior and poste- 
rior fissures, and contains within it the ventricle of the cord. The poste- 
rior limb of each crescent constitutes the posterior horn of gray matter, 
the anterior limb the anterior horn. In the latter are situated distinct 
groups of large multipolar cells, which appear to be the nuclei of origin of 
the anterior or motor nerves, and from it the root of each nerve passes 
forwards through the substance of the white matter in several parallel 
bands. The posterior horn is tipped by the gelatinous substance of Eolando, 
from the whole transverse extent of which the fibres of each posterior root 
escape in wavy bands, some undulating through the substance of the ad- 
joining posterior column previous to their appearance at the surface of the 
cord. At the root of the posterior cornu, on its outer side, is the group of 
cells which indicates the longitudinal tract to which Lockhart Clarke has 
given the name of tractus inter medio -lateralis ; and in almost the corres- 
ponding situation, on its inner side, may be seen the sectional surface of 
the tract of cells which constitutes Clarke's posterior vesicular column. 
The gray matter varies in bulk in different parts of the cord, and is espe- 
cially abundant in the cervical and lumbar enlargements, but the superfi- 
cial white matter increases absolutely in quantity from below upwards. 

7. Medulla oblongata At the upper part of the cord, where it merges 

in the medulla oblongata, considerable changes are presented in the distri- 
bution of its parts. These changes become more and more remarkable as 
we proceed from the lower to the upper part of the medulla oblongata, 
and are complicated by the appearance of additional gray nuclei. The 
posterior fissure opens out and blends with the ventricle of the cord ; the 
posterior pyramids are divaricated, forming between them the calamus 
scriptorius ; and the remainder of the posterior columns, now constituting 
the restiform bodies passes upwards and outwards to form the inferior 
peduncles of the cerebellum ; in front of these is gradually developed, on 
either side, a gray column, due to the altered position of the gelatinous 
substance of Rolando ; still further forwards we see the seeming blending 
of each lateral column with its olivary body, and in front the anterior col- 



ANATOMY AND PHYSTOLOGY. 



817 



umns, apparently continued upwards into the anterior pyramids. The 
arrangement of parts here is exceedingly complicated. But it may be 
stated generally: that the bulk of each posterior column of the cord passes 
upwards in the restiform body to the cerebellum ; and that, according to 
Meynert, it has in its passage upwards a direct connection with the olivary 
body, and that in this region decussation of the tracts of opposite sides 
takes place, so that the relation between the cord and cerebellum becomes 
crossed ; that the greater part of the white substance of each antero-lateral 
column decussates with the corresponding part of the opposite side at the 
lower extremity of the anterior pyramid ; and that each pyramid is hence 
constituted mainly by the continuation upwards of the medullary matter of 
the opposite side of the cord to that on which it is itself situated, and then, 
passing through the substance of the pons Varolii, forms in front of it the 
larger bulk of the crust of the corresponding cerebral peduncle ; and lastly 
that some portion of the fibres of the lateral columns, and most of the 
opened-out gray matter of the cord pass upwards along the floor of the 
fourth ventricle and back of the pons Varolii, partly to form the tegmen- 
tum, partly to become associated with the gray matter of the iter and third 
ventricle. 

8. Cerebrospinal nerves The cerebro- spinal nerves, with only two 

exceptions, originate in the gray matter of the spinal cord, or its continu- 
ations in the medulla oblongata, along the floor of the fourth ventricle, 
and around the iter. They are of two kinds, motor and sensory. The 
motor spinal nerves have their immediate origin in the groups of large 
cells contained in the anterior cornua, and emerge at the surface of the 
cord in the furrow separating the anterior from the lateral columns ; the 
sensory nerves originate apparently in the posterior cornua, and make their 
appearance superficially in the groove which divides the lateral from the 
posterior columns. 

The cerebral nerves, in the main, arise according to their properties in 
the upward continuations of the motor and sensory tracts of the gray 
matter of the cord ; in other words, the motor nerves spring from the up- 
ward continuation of that portion of gray matter which is anterior to the 
spinal ventricle, the sensory nerves from the upward continuation of that 
portion which is behind it. But these tracts, as has been shown, become 
modified in their relative positions in the medulla oblongata and floor of 
the fourth ventricle ; the motor tract gets superficial on either side of the 
median line in the course of the fasciculi teretes ; the sensory tract, on the 
other hand, split into two halves, continues upwards on either side of the 
motor tract, occupying each lateral half of the floor of the ventricle, spread- 
ing out on either side along the inner aspect of the cerebellar peduncles 
towards the cerebellum, and at the anterior point of the fourth ventricle 
rising up and coalescing again, as in the cord, over the iter or tubular con- 
tinuation of the ventricle. 

The motor nerves, in their order from behind forwards, are the spinal 
accessory and hypoglossal, the portio dura, the abducens or sixth, the 
motor branch of the fifth, the fourth, and the third. The upper part of 
the spinal accessory arises from a nucleus situated in the lower part of the 
medulla oblongata, a little outside the central canal, and concealed by the 
posterior pyramid ; and it becomes superficial as the lowermost member of 
the eighth pair at the lateral aspect of the medulla below the level of the 
olivary body. The nucleus of the ninth, or hypoglossal nerve, commences 
below in front of the spinal canal, in contact with the spinal accessory 
52 



818 



DISEASES OF THE NERVOUS SYSTEM. 



nucleus, and extends for a short distance along the floor of the fourth ven- 
tricle in the neighborhood of the calamus scriptorius. Its superficial ori- 
gin is between the olivary body and the anterior pyramid. The common 
nucleus of the portio dura of the seventh pair and abducens is situated 
just in front of the hypoglossal nucleus. The former nerve becomes super- 
ficial at the posterior margin of the pons, between the middle and inferior 
peduncles of the cerebellum ; the latter in the groove between the anterior 
pyramid and the pons. The nucleus of the motor-root of the fifth pair is 
situated within the fasciculus teres, a little above, in front of, and external 
to that of the portio dura ; the nerve becomes superficial by penetrating 
the lateral portion of the pons. The third and fourth pairs arise in com- 
mon from a pair of nuclei, situated side by side in the floor of the iter. The 
fourth nerves encircle the iter in their course, and then winding round the 
outer side of the crura cerebri reach the base of the brain ; each third nerve 
penetrates the subjacent locus niger, and makes its appearance on the inner 
side of the cms. 

The sensory nerves, in their order from behind forwards, are the vagus 
and glosso-pharyngeal, the auditory, and the sensory portion of the fifth; 
to which may be added the optic and the olfactory. The nucleus of the 
vagus, connected with that of the spinal accessory below, appears on the 
floor of the fourth ventricle just above the calamus and external to the 
hypoglossal nucleus. Above, it appears to sink beneath the auditory nu- 
cleus. The glosso-pharyngeal nucleus, which is partly continuous with 
that of the par vagum, but higher up, is wholly concealed by the auditory 
nucleus, with which it is in some measure blended. These two nerves 
become superficial along the posterior border of the olive. The auditory 
nucleus is of large size; it involves the upward continuation of the gray 
matter of Rolando, and, in part, the posterior pyramid and restiform body. 
It occupies the floor of the ventricle external to the fasciculus teres, and 
its outer part turns backward with the restiform body to reach the cere- 
bellum, some portion of it becoming connected with the dentate nucleus, 
some stretching across the roof of the ventricle to join its fellow. The 
nerve-fibres arising from this nucleus, taking various routes, combine to 
form the portio mollis, which has its superficial origin at the posterior 
margin of the pons, between the superior and middle cerebellar peduncles. 
The nucleus of the sensory portion of the fifth is, like the auditory, largely 
developed out of the upward continuation of the gray tubercle of Rolando, 
and also from that of the root of the posterior horn. It is situated in ad- 
vance of the nucleus of the portio mollis, with which indeed it is, to some 
extent, connected behind, and extending upwards to the fossa, where the 
fillet meets the anterior fibres of the pons, arches backwards with the rest 
of the continuation of the gray matter from the cord towards the side and 
roof of the anterior part of the fourth ventricle and of the adjoining part 
of the iter. The superficial origin of the nerve is to the anterior and 
outer part of the pons Varolii. The optic nerves interlace in the chiasma, 
and thence each optic tract winds round the corresponding crus cerebri to 
reach the posterior portion of the optic thalamus, the corpora geniculata, 
and the corpora quadrigemina of the corresponding side, which therefore 
may be regarded as its nuclei, or, at all events, as containing its nuclei ; 
but, further, the optic tract, in its whole extent, is intimately connected 
structurally with the crus cerebri, and the chiasma with the gray matter 
lining the third ventricle. The olfactory nerve is really, as comparative 
anatomy has long shown, a lobe of nervous substance. It is formed of 



ANATOMY AND PHYSIOLOGY. 



819 



gray and white matter, and contains, according to Meynert, a central ven- 
tricle continuous with those of the cerebrum, which, however, according 
to Struthers, is absent in the adult ; its so-called roots are connected respec- 
tively with the anterior and posterior extremities of the gyrus fornicatus, 
and some of the white fibres connected with it have been traced into the 
anterior commissure. It is an important fact that the fibres of the ante- 
rior commissure are connected with the occipital and temporo-sphenoidal 
lobes only, and that hence the olfactory nerves, and, it may be added, from 
their connection with the optic thalami and associated ganglia, the optic 
nerves, are both intimately connected with that portion of the brain with 
Avhich, through the intermediation of the same ganglia, the rest of the sen- 
sory nerves are connected. 

9. Resume of the relations of the different parts of the central nervous 

system The anterior portion of the surface of the brain (all that in front 

of the fissures of Rolando, together with the ascending parietal convolu- 
tions behind those fissures, and certain other convolutions connected there- 
with) appears on sufficiently good grounds to be regarded as the supreme 
organ of the cerebro-motor processes or impulses ; and indeed, as will 
presently be pointed out, pathological and experimental investigations 
have demonstrated that certain definite regions of this area are connected 
with certain special groups of combined movements. From all this extent 
of surface radiating fibres converge to certain parts at the base of the 
brain, namely, the caudate and lenticular nuclei of the corpora striata and 
the white matter (the internal capsules) which lies between these bodies 
and the optic thalami. Of these radiating fibres some pass without inter- 
ruption through the internal capsules, while others enter the nuclei of the 
corpora striata. Below these nuclei, the fibres passing uninterruptedly 
through the internal capsules, together with others given off from the under 
surface of the corpora striata, form the crusts of the crura cerebri, which, 
continued downwards through the pons Varolii, emerge from its posterior 
and lower border in the form of the anterior pyramids of the medulla ob- 
longata. Hitherto the fibres derived from each cerebral hemisphere have 
travelled downwards and backwards on the corresponding side of the 
body ; at the loAver part of the anterior pyramids, however, decussation 
takes place, and the fibres of the anterior pyramid of one side are continued 
downwards, mainly along the anterior and lateral white columns of the 
opposite side of the cord. But, in addition to the corpora striata, with 
which bodies all the fibres passing from the cerebro-motor region of the 
brain have, in their passage downwards, a more or less intimate connection, 
there are, imbedded as it were in each lateral motor tract, a series of 
subordinate motor centres or nuclei, succeeding one another in close suc- 
cession from the floor of the iter above to the termination of the cord below, 
each one of which gives origin to a motor nerve or to a certain number of 
fibres going to the constitution of a motor nerve. 

It follows generally from the above account that complex motor im- 
pulses, originating in the hemispheres of the brain, are conveyed along the 
radiating fibres to the corpora striata, through the agency of which bodies, 
resolved as it were into their simplest elements, they are transmitted to 
the several subordinate cerebral and spinal nuclei which immediately 
govern the movements of those muscles, which in combination effect in- 
tended results. It follows generally also that impulses originating in one 
cerebral hemisphere act through the corpus striatum of the same side upon 
the spinal nuclei of the opposite side of the body, and hence upon the 



820 



DISEASES OF THE NERVOUS SYSTEM. 



muscles of the opposite side of the body. It must be added that the same 
holds good of those motor nerves whose origins are situated above the 
decussation of the pyramids. There are, however, certain exceptions to 
these statements, due doubtless to the fact of the intimate connection by 
means of commissural fibres between the two hemispheres of the brain, 
and especially to the similar connection which subsists between the cor- 
responding motor nuclei of opposite sides along the motor tracts. These 
exceptions are presented •especially by the motor nerves of the eyes, and 
by the nerves concerned in phonation, respiration, and other acts in which 
the corresponding muscles of opposite sides of the body habitually act in 
unison or concert. Further, it must not be forgotten that every subordi- 
nate motor centre has independent motor powers, which, if it retain its 
connection with its correlated afferent centre, are capable of being brought 
into action by reflex stimulation : that, if the cerebrum be removed, or its 
functions in abeyance, combined movements, to all appearance voluntary, 
may be effected through the immediate agency of the corpus striatum ; 
that if the spinal centres be cut off from their connection with the higher 
centres, these also are capable of inducing reflex movements ; and that 
under various conditions of health and disease the independent action of 
these various subordinate centres is a fact of more or less importance. 

The afferent or sensory nerves, which near their entrance into the spinal 
marrow are furnished with ganglia, penetrate into the posterior cornua, 
and thus become connected with that portion of gray matter lying behind 
the central canal which constitutes the sensory region of the spinal cord. 
This sensory region occupies the whole length of the cord, and at the me- 
dulla oblongata becomes split longitudinally from before backwards, both 
halves passing upwards, one on either side of the now superficial motor 
nuclei of the medulla oblongata, to form the tegmenta and to become con- 
nected with the optic thalami, corpora geniculata, and corpora quadri- 
gemina, and thus with the nuclei of origin of the optic nerves. From 
these ganglia radiating fibres proceed mainly to the gray cortex of the 
posterior portions of the cerebrum or to the true sensorium. Thus it ap- 
pears that the posterior part of the cerebral surface has some such relation 
with the sensory functions as the anterior has with the motor functions, 
and the optic thalami and ganglia behind them some such connection with 
the same system as the corpora striata have with the motorial. And 
further, it seems probable (judging at all events by the analogies afforded 
by the organs of seeing and hearing) that complicated external impressions 
become analyzed or disentangled, as it were, or reduced to their simplest 
elements by the organs which first receive them; to become again blended 
into a whole, so to speak, in their onward progress to the sensorium. Both 
experiment and pathology have shown conclusively that the sensory tracts 
decussate equally with the motor ; and that the cerebral hemisphere and 
optic thalamus of one side are in direct relation with the sensory tract and 
nerves of the opposite half of the medulla oblongata and spinal cord. The 
decussation does not, however, take place in the pyramids or at any one 
spot ; but each sensory nerve immediately after its entry into the gray 
matter of the cord decussates with its fellow of the opposite side, and its 
fibres of communication with the optic thalamus continue thenceforward 
to pass upwards on the same side as that body. 

The relations of the cerebellum with the motor and sensory tracts as 
they traverse the base of the eneephalon, and which are such that (con- 
trary to what obtains in the cerebrum) each lateral lobe is functionally 



ANATOMY AND PHYSIOLOGY. 



821 



connected with its own .side of the body, have already been considered, 
and its connection with the posterior columns of the cord through the inter- 
vention of the restiform bodies has also been pointed out. It is further 
established that the posterior columns of the cord are in no sense the con- 
ductors of ordinary sensory impressions, as from their position was formerly 
supposed, but that whether afferent or merely commissural they are mainly 
subservient to the co-ordinating functions. 

It is important to bear in mind : that at the base of the brain, and 
especially in the situation of the pons Varolii and medulla oblongata, the 
sensory and motor tracts of both sides become to some extent intermingled, 
that the nuclei of origin of many nerves of the highest interest and import- 
ance are crowded together into a very small space, and that hence disease 
affecting these parts is liable to be attended with complex, aggravated, 
and it may be added striking features ; and that as regards the cord the 
sensory tracts although probably in part occupying the lateral white 
columns are mainly imbedded in its interior, while nearly all the white 
matter which forms its peripheral portion as well as the anterior cornua 
belong to the motor system, and that hence the sensory columns are spe- 
cially protected from the influence of pressure or other injurious influences 
operating from without. 

10. Localization of function — a. Pathological observation and recent 
experimental researches have combined to prove : that certain definite 
areae of the gray surface of the cerebral hemispheres are the seats of special 
endowments; and that their stimulation is attended with certain specific 
consequences for the most part revealed by definite groups of movements, 
their destruction by equally specific consequence of an opposite or paralytic 
kind. It need scarcely be said that experimental investigation has been 
conducted almost exclusively on the lower animals, and that hence the de- 
termination of the areae above referred to in relation to the human brain 
can only be regarded as approximative. The positions assigned to these 
areae or centres by Dr. Ferrier are shown in Figs. 5, 6, and 4. 1 

It will there be seen: that the centre (v.) for movements of the lips and 
tongue occupies the posterior part of the third frontal and the lower part 
of the ascending frontal convolutions ; and that in immediate relation with 
this are the centres, (vi.) for the depression of the angle of the mouth, 
(vii.) for its elevation — both seated in the ascending frontal — and (ix.) for 
its retraction with contraction of the platysma — occupying the lower part 
of the ascending parietal. At the upper part of the ascending frontal, en- 
croaching however on the neighboring ascending parietal and on the first 
frontal, is situated the centre (iii.) for complex movements of the arm and 
leg, as in climbing, swimming, and the like ; immediately in front upon 
the first frontal the centre (ii.) for extension of the hand and arm ; and 
just behind it, and occupying partly the upper extremity of the ascending 
parietal and partly the superior parietal the centre (iv.) for movements of 
the leg and foot, as in locomotion. The centres marked (x.), occupying 
the greater part of the ascending parietal, are connected with movements 
of the hand and wrist; and that marked (i.), seated in the first and second 
frontal convolutions, is correlated with lateral movements of the head and 
eyes to the opposite side, elevation of eyelids, dilatation of pupils, and 
generally the look of surprise. It will be observed that all the above cen- 

1 For much, of what follows see Dr. Ferrier on the 'Functions of the Brain,' 
1876. 



822 



DISEASES OF THE NERVOUS SYSTEM. 



tres are included in that area of the surface of the brain which is in special 
relation through the corpus striatum with the motor tract, and which, 



Fig. 5. 




Lateral view of brain, showing Terrier's centres of movements. 



Fig. 6. 




Upper aspect of brain, showing principal convolutions and fissures ; and on the left side Ferrier's 
centres of movements, and on the right the arterial arese. 

The Eoman numbers in the above figures, and in Fig. 4, refer to Ferrier's centres. 

i., lateral movements of head and eyes, with elevation of eyelids and dilatation of pupils ; ii., 
extension of arm and hand ; iii., complex movements of arm and leg, as in climbing, swimming, 
&c. ; iv., movements of leg and foot, as in locomotion ; v., movements of lips and toDgue, as in 
articulation ; vi., depression of angle of mouth ; vii., elevation of angle of mouth ; viii., supination 
of hand and flexion of forearm ; ix., centre of platysma — retraction of angle of mouth ; x., move- 
ments of hand and wrist; xi., centre of vision; xii., centre of hearing; xiii., centre of touch; 
xiv., centre of smell and taste. 



ANATOMY ANT) PHYSIOLOGY. 



823 



according to M. Betz, contains giant-cells resembling those of the anterior 
cornua of the cord. 

Below and behind the interparietal and Sylvian fissures is a series of 
centres which, though associated like the others with more or less definite 
movements, are really sensory centres; the movements due to their stimu- 
lation being excited reflectorially through the motor centres, and their 
destruction being unattended with a loss of muscular power. The first of 
these (represented by a group of circles numbered xi.), which occupies 
the whole extent of the supra-marginal convolution and pli courbe, is the 
centre of vision. Its destruction causes temporary blindness of the oppo- 
site eye ; the destruction of both causes permanent and absolute blindness 
of both eyes. Its irritation appears to evoke subjective visual phenomena 
in the opposite eye with turning of the eyeballs, and frequently of the 
head, towards that side, and contraction of the pupils. The second of 
these (xii.) corresponds to nearly the whole of the first temporo-sphenoidal 
convolution. It has a similar relation to hearing that the last has to see- 
ing. Destruction of this part involves absolute loss of hearing on the 
opposite side; irritation causes sudden pricking of the opposite ear, and 
turning of the head and eyes in the same direction, with opening of the 
eyes and dilatation of the pupils. The third (Fig. 4, xiii.), situated in 
the hippocampal region, appears to be the centre for tactile sensation. Its 
destruction is attended with hemianesthesia; its irritation Avith movements 
indicative of pain or uneasiness in the opposite side of the body. The last 
(Fig. 4, xiv.) is the centre of smell ; intimately associated with which, 
though as yet impossible of exact localization, is the centre of taste. Irri- 
tation of the centre of smell induces torsion of the upper lip and partial 
closure of the nostril on the same side as the centre; its destruction 
abolishes the sense of smell in the same nostriL Irritation of the part of 
the surface of the brain concerned in taste provokes movements of the 
lips, tongue, and cheeks; its destruction involves the abolition of the gus- 
tatory sense in the opposite side of the mouth. It is important to note 
that these sensory centres occupy that part of the brain which is in special 
relation with the sensory tract, and which, as M. Betz shows, presents an 
almost total absence of giant-cells. 

There are certains parts of the cerebral surface the effects of irritation 
of which are negative. These are especially, the internal aspect of each 
hemisphere including the gyrus fornicatus, the island of Reil, the occipital 
lobe, and the anterior parts of the frontal lobe including that part which 
overlies the orbit. But nevertheless Dr. Ferrier adduces plausible argu- 
ments : for believing that the occipital lobe has some definite relation to 
visceral sensation, and that its destruction is attended with abolition of 
appetite for food associated with depression and apathy, and, in general, 
speedy death ; and for regarding the anterior part of the frontal lobe as 
being specially connected with the intellectual functions, its destruction 
being attended with apathy, dulness, disposition to sleep, and loss of the 
faculty of attentive and intelligent observation. 

It should be added to the above summary that Drs. Dupuy and Burdon 
Sanderson have shown that the specific motor powers above considered 
(so far as they can be tested experimentally) do not reside absolutely in 
the gray matter of the convolutions ; but that in most cases similar motor 
effects may be produced by exciting, after successive removals, each suc- 
cessive surface of that wedge of brain-substance of which the base corre- 
sponds to the particular superficial motor area, and the apex to a point in 



824 



DISEASES OF THE NERVOUS SYSTEM. 



the corpus striatum. Dr. Sanderson, indeed, says that the movements are 
produced most distinctly when the irritation is affected directly upon the 
corpus striatum. 

Finally, in reference to the surface of the brain, it must be pointed out 
that the posterior extremity of the third frontal convolution of the left side, 
or Broca's convolution, is, judging from pathological evidence, the centre 
of the faculty of articulate language. With this conclusion Ferrier's ex- 
perimental results are reasonably accordant. 

b. As might naturally be supposed, from its relations to the hemisphere 
above and to the medulla oblongata and cord below, destruction of the 
corpus striatum is attended with paralysis of voluntary motion of the oppo- 
site side of the body, excepting in so far as this is obviated by the intimate 
connections subsisting between those collateral spinal nuclei supplying 
opposite muscles which habitually act in unison. Irritation of this gan- 
glion causes spasmodic contraction of the muscles on the opposite side of 
the body. 

c. It seems clear that the optic thalamus has the same relation to sen- 
sation, including tactile sensation, sight, hearing and taste (but probably 
not to smell) that the corpus striatum has to motion. Irritation of this 
body is unattended with motor manifestations, but its destruction involves 
hemianesthesia of the opposite side of the body, including loss or im- 
pairment of taste and hearing, impairment of smell, due to anaesthesia in 
the domain of the fifth nerve, and blindness. Dr. Hughlings Jackson 
records a case of destruction of the optic thalamus by disease, in which 
together with the phenomena above enumerated there was loss of sight 
in the half of each retina on the same side as the lesion. It has been 
maintained by many physiologists that the optic thalamus has not the con- 
nection with sensation here assigned to it, but that the posterior part of the 
internal capsule is the direct channel for the transmission of peripheral 
sensory impressions to the surface of the brain. There is no doubt that this 
is so far true that destruction of this part causes, like destruction of the 
thalamus, opposite hemiangesthesia ; but this is due to the fact that the in- 
ternal capsule is the medium of communication between the brain and 
thalamus. 

d. Whatever other functions may belong to the cerebellum, at any rate 
this portion of the encephalon appears beyond all doubt to be the supreme 
centre for the regulation of ' the various muscular adjustments necessary 
to maintain the equilibrium of the body.' But the maintenance of equi- 
librium demands, not only a central organ, but a sensory or afferent mech- 
anism by which the central organ may be kept informed of the condition 
of the body in relation to equilibrium, and an efferent or motor mechanism 
by means of which muscular adjustment may be affected. The former of 
these are the organs of common sensation, the eyes, and more important 
than all the semicircular canals with their afferent nerves ; the latter are 
the motor nerves and voluntary muscles. 

Experimental lesions of the cerebellum always induce disorders of equi- 
librium but never impairment of sensation, or actual loss of voluntary mus- 
cular power. Without entering into any physiological explanation of the 
phenomena, we may briefly state that experimental evidence proves that 
destructive lesions of the anterior part of the middle lobe cause a tendency 
to fall forwards, of the posterior part of the middle lobe a tendency to fall 
backwards, of the right lobe a tendency to turn to the left (in the case of 
one of the lower animals, therefore, or of a person lying down, to roll from 



ANATOMY AND PHYSIOLOGY. 



825 



left to right, or towards the injured side), and of the left lobe a tendency 
to turn to the right ; and that precisely converse tendencies result from 
irritation of the same parts. Attending these movements there is spas- 
modic contraction of the muscles of that side of the body towards which 
twisting occurs ; and when the lateral lobes are affected the twist com- 
mences with spasmodic torsion of the head and neck. Usually also there 
is conjugate deviation of the eyes to the right, left, upwards or downwards, 
in accordance with the direction of the general bodily movements, or more 
or less nystagmus. Lesions of the structures connected with the cerebellum 
are also attended with disturbance of equilibrium : division or destruction 
of the middle peduncle of the cerebellum on either side causing the same 
symptoms as destructive lesions of the corresponding cerebellar lobe ; and 
irritation and injury of the corpora quadrigemina equally inducing inco- 
ordination of movement. It must be added that affections of the semi- 
circular canals produce the same consequences as regards equilibrium as 
affections of the cerebellum : affections of the superior vertical canals 
being equivalent to affections of the anterior part of the middle lobe ; 
affections of the posterior vertical canals to those of the posterior part of 
the middle lobe ; and affections of the horizontal canals to those of the 
corresponding lateral lobes. 

e. The corpora quadrigemina are through the corpora geniculata brought 
into immediate relation with the optic tracts, and, indeed, there is no doubt 
that these bodies are the subordinate centres of vision, and have reflex 
connections with the motor nerves of the eyes. In the lower animals de- 
struction of one optic lobe causes blindness of the opposite eye and more 
or less immobility of the pupil ; irritation induces sudden starting back- 
wards of the animal as if in alarm, turning of the eyes and head to the 
opposite side, dilatation of the pupils, and more or less spasmodic contrac- 
tion of the facial muscles with trismus and opisthotonos. It is important 
to note that the pupils are completely paralyzed only when the destruction 
of these bodies is bilateral ; and that when irritation causes dilatation of 
the opposite pupil, dilatation of the pupil of the sound side speedily follows. 
In man destruction of one of the anterior tubercles of the corpora quad- 
rigemina appears to cause hemianesthesia in both eyes on the same side 
as the lesion. There are good reasons for believing that the testes are 
particularly connected with some forms of emotional expression. We 
have already referred to the relation of the corpora quadrigemina to equi- 
librium. 

From the anatomical facts which have been detailed it is obvious that 
the medulla oblongata, including all that region from which the cerebral 
nerves arise, is the chief centre of many important functions which are 
more or less essential to the maintenance of life. It is clearly established, 
indeed, that even in warm-blooded animals all the centres above the 
medulla oblongata may be removed without destroying life ; and that with 
the medulla oblongata remaining respiration and deglutition are still capa- 
ble of performance. The medulla is in fact the co-ordinating centre of the 
respiratory acts, of phonation, of articulation, of facial expression, and of 
the acts of sucking and deglutition. Moreover, it is the centre of inhibition 
and acceleration of the action of the heart, and the centre of innervation 
of the bloodvessels. The co-ordinating centre of respiration is placed by 
Flourens in the angle of the calamus scriptorius. 

g. As regards the cord all that we need add to statements already made 
is : that like the medulla it is a centre, though subordinate centre, of reflex 



826 



DISEASES OF THE NERVOUS SYSTEM. 



action ; that cut off from its connection with the parts above it is capable 
through its afferent and efferent connections of producing co-ordinated move- 
ments ; that under such circumstances irritation of the ends of sensory 
nerves generally causes reflex movements of the part with which the irri- 
tated nerves are in relation ; that if the irritation be extreme or the cord 
unnaturally irritable the influence instead of remaining limited becomes 
diffused horizontally and perpendicularly throughout the cord, so that re- 
flex phenomena, instead of being confined to a particular district, become 
more or less widely distributed ; that the tone of muscles, and consequently 
the action of the sphincters, is due to reflex action in constant automatic 
operation ; and, lastly, that the nutrition of muscles and probably of other 
tissues, and secretion, are largely influenced directly or indirectly by the 
spinal cord. 

h. We only deem it necessary to remark in conclusion upon the olfactory 
and the optic nerves. There is good reason to believe, partly on anatomi- 
cal, but mainly on pathological, grounds, that the olfactory nerves, unlike 



L e and r e, left and right eyes ; c, chiasma ; l g and it G, left and right geniculate bodies ; q, 
corpora quadiigemina ; l h aud r h, left and right centres of vision ; b and a, nerve-fibres from 
left and right sides respectively of left eye ; b, and a, corresponding fibres from right eye. 

all others, do not decussate, or at any rate that the olfactory nerve of each 
side is connected chiefly with the supreme centre of smell of the same side. 
The arrangement and course of the optic nerves are peculiar. But experi- 
ment and clinical observation demonstrate facts in relation to them which 
anatomy alone does not teach us. We have shown that destruction of the 
supreme centre of sight on one (say the left) side causes total blindness of 
the right eye, a result which equally follows destruction of the right optic 
nerve; whereas destruction of the optic tract, corpora geniculata, or corpora, 
quadrigemina of one side causes hemiopia of both eyes. A reasonable ex- 
planation of these phenomena is offered in the accompanying diagram, for 
which we are indebted to Prof. Charcot. 

11. Sympathetic system. — The sympathetic system of nerves appears to 
have its supreme centre in the medulla oblongata, or rather on the floor of 
the fourth ventricle; but it is intimately interwoven with the spinal sys- 
tem, and, as is well known, each spinal nerve receives branches from, and 



Fig- 7. 




IH RH 

Scheme of decussation of optic tracts. 



I 



ANATOMY AND PHYSIOLOGY. 



827 



transmits branches to, a neighboring sympathetic ganglion. "We need not 
consider the anatomical details of this system ; it is sufficient to point out 
that it presides over the shortening and lengthening of the organic muscu- 
lar fibres wheresoever situated, that it determines the dilatation and con- 
traction of the bloodvessels, and therefore the amount of blood supplied to 
various parts, and in some degree the rapidity of its flow through them, 
and that it thus regulates to some extent the nutritive and other functions 
of the different parts of the organism and their temperature. There is some 
reason also to believe that special branches are supplied to the secreting 
cells of some, if not of all, of the glandular organs, and that hence a direct 
influence is exerted by it over the physiological processes which go on in 
these organs. 

12. Arteries of brain The meningeal arteries are derived mainly from 

branches of the external carotids ; but a minute branch is furnished also 
by each vertebral immediately after its entrance into the skull. They have 
no connection with the arteries which supply the brain and its vascular 
membrane, the pia mater. 

The proper arteries of the brain are derived from the internal carotids 
and the vertebrals, which, after entering the skull and giving off certain 
branches, to some of which we shall presently again refer, form between 
them that remarkable anastomosis known as the circle of Willis. Each 
internal carotid artery having first given off the ophthalmic and then the 
posterior communicating artery, divides into two branches, namely, the 
anterior and the middle cerebral. The anterior cerebral (Figs. 6, 8, 9, 
and 10), which is the smaller of the two, anastomoses after a short course 
with its fellow by the anterior communicating artery. Its trunk then 
turns round the anterior edge of the corpus callosum, and runs backwards 
along the upper surface of that body. It divides into three principal 
branches of which the first is distributed superficially to the orbital convo- 
lutions below, and to a small portion of the inner aspect of the hemisphere 
in the neighborhood ; the second is distributed to the first frontal convolu- 
tion, to the greater part of the second, to the upper extremity of the 
ascending frontal, and to all that part of the inner aspect of the hemisphere 
which lies between the area of distribution of the first branch and the 
ascending limb of the fronto-parietal fissure, including the anterior two- 
thirds of the corpus callosum ; the third branch supplies that area of the 
inner surface of the hemisphere which lies between the ascending limb of 
the fronto-parietal and also the parieto-occipital fissure, and also the poste- 
rior part of the corpus callosum. The middle cerebral artery (Figs. 6, 8, 9, 
and 10) divides in the fissure of Sylvius into four branches, which, radi- 
ating in conformity with the convolutions of the island of Reil, and supply- 
ing them with vessels, emerge on to the outer surface of the brain, and are 
thus distributed : — the anterior or first branch ramifies over the third fron- 
tal convolution exclusively ; the second is distributed to a portion of the 
second frontal convolution and to almost the whole of the ascending fron- 
tal ; the third supplies mainly the ascending parietal and superior parietal 
convolutions, the posterior and lower limit of its distribution being indicated 
partly by the inter-parietal fissure, and partly by a horizontal line drawn 
from this to a point on the upper margin of the hemisphere midway between 
the fronto-parietal and parieto-occipital fissures ; the fourth or posterior 
branch is distributed to the first and second temporal convolutions, and to 
the gyrus angularis, its posterior limit being determined by a line drawn 
from the posterior extremity of the second temporal sulcus to the parieto- 



828 



DISEASES OF THE NERVOUS SYSTEM. 



occipital. The posterior cerebral arteries (Figs. 6, 8, 9, and 10) result 
from the division of the basilar; each sends branches into the brain-sub- 
stance of the locus perforatus posticus, is then joined by the posterior 
communicating artery of the same side, and finally gives off* three principal 



Fig. 8. 




Lateral view of brain, showing arterial arese. 



Fig. 9. 




Inner surface of cerebral hemisphere, showing arterial arese. 

In the above figures, and also in Figs. 6 and 10, the clotted surfaces correspond to the anterior 
cerebral artery ; the clear surfaces to the middle cerebral; the shaded surfaces to the posterior 
cerebral. The sub-divisions of these surfaces made by dotted lines indicate the arese supplied by 
the principal branches of the above arteries, and the Arabic numbers attached to them the order 
of the branches from before backwards. 

branches, which are distributed to all those parts of the cerebral surface 
which have been hitherto unaccounted for : the anterior to the uncinate 
convolution ; the middle to the third temporal and the fusiform or lateral 
occipito-temporal convolutions, and to the hinder part of the gyrus forni- 
catus ; and the posterior to the median occipito-temporal convolution, to 
the cuneus, and to the occipital lobe. 

The distribution of the arteries to the ganglia at the base of the brain 
is not less important than that upon the surface of the organ. All three 
pairs of cerebral arteries, for the most part, take a share in supplying these 



ANATOMY AND PHYSIOLOGY. 829 

bodies. The anterior cerebral gives small branches to the anterior extre- 
mity only of the caudate nucleus, and not unf'requently none at all. The 
middle cerebral, on the other hand, has a comparatively wide and very 
important distribution. It gives off many branches of somewhat larger 



Fig. 10. 




Under surface of brain, showing principal convolutions and fissures and the arterial areas. 

size, which, entering at the locus perforatus anticus at right angles, or 
nearly so, to the trunk, supply the whole of the lenticular nucleus of the 
corpus striatum, the whole or greater part of the caudate nucleus, the in- 
ternal capsule, and the anterior and outer part of the optic thalamus. They 
may be divided into two groups : an internal group, consisting of compara- 
tively small vessels, which are distributed to the internal portions of the 
lenticular nucleus, and to the adjoining portions of the internal capsule ; 
and an outer group of vessels of considerably larger size, which course 
mainly over the outer aspect of the lenticular nucleus, and supply the 
outer part of that body, and also, according to their position, the caudate 
nucleus or the optic thalamus. One of these branches, called by Charcot 
' the artery of cerebral hemorrhage,' is pre-eminently large, and, after 
penetrating the outer part of the lenticular nucleus, and traversing the in- 
ternal capsule, enters the substance of the caudate nucleus, and passes from 
behind forwards in it to its most anterior part. The posterior cerebral arteries 
give branches to the choroid plexuses and ventricular walls, and supply also 
the tegmentum, the corpora quadrigemina, and the posterior and inner parts 
of the optic thalami. The branches which they give to the last-named bodies 
may be divided into internal and external. The former supply the inner 
aspects of the thalami, and their rupture is apt to be followed by the profuse 
escape of blood into the ventricular cavities ; the latter supply the outer 



830 



DISEASES OF THE NERVOUS SYSTEM. 



parts of the thalami, and since, before they enter them, they pass through 
the cerebral peduncles, their rupture is apt to be attended with effusion of 
blood into the substance of these bodies. 

The vertebral arteries unite to form the basilar, which divides in front 
into the two posterior cerebrals. The vertebrals, besides supplying me- 
ningeal and spinal branches, give off on either side a posterior inferior 
cerebellar artery, which is distributed to the hinder portion of the lower 
aspect of the cerebellum and to the choroid plexuses of the fourth ven- 
tricle. The basilar, in addition to sending a branch to each internal 
ear. and other branches to the substance of the pons, gives off also a 
right and a left anterior inferior cerebellar artery to the anterior part of the 
under surface of the cerebellum, and a right and a left superior cerebellar 
artery, which are distributed over the whole of the superior surface of the 
cerebellum, and supply the valve of Yieussens and partly the velum inter- 
posit -urn. 

It is necessary to bear in mind — for, indeed, it is this fact which makes 
an accurate acquaintance with the details of the cerebral circulation im- 
portant — that, save at the circle of TVillis, little or no communication takes 
place between the branches of the cerebral arteries even down to their 
finest ramifications, excepting by means of capillary vessels ; and that 
hence, if any artery become obstructed, the region to which it leads almost 
necessarily suffers in its whole extent. Thus, if the middle cerebral be 
blocked, the nutrition of the whole region to which it is distributed be- 
comes impaired ; if one of its primary branches be obstructed, the limit- 
ation of morbid change is equally definite ; and, if a secondary or even 
smaller vessel be alone involved, secondary changes will be limited to cor- 
respondingly minute districts. It is further important, in reference to this 
point, to know that the arteries on the surface of the convolutions give off 
long and short branches, which are quite distinct from one another ; and of 
which the short are distributed to the cortical gray matter, the long enter 
the white substance, and are limited in their distribution to it. It is scarcely 
necessary to add that the ultimate arteries supplying the ganglia are equally 
distinct from both. 

It is a matter of no slight practical importance that the ophthalmic 
artery arises from the same trunk as that which gives off the anterior and 
middle cerebral arteries ; and that it supplies not only the eyeball itself, 
but the contents of the orbit including the lachrymal gland, and gives off 
branches tp the eyelids and contiguous parts of the forehead and nose, and 
to the ethmoidal cells. The arteries of the internal ear again are mainly 
derived from one of the intra-cranial arteries, namely, the basilar. 

13. Veins of brain The veins distributed over the surface of the cere- 
brum and cerebellum open into the several sinuses to which they are 
respectively contiguous. Those situated within the lateral ventricles con- 
verge to the vena? Galeni, by means of which they empty themselves into 
the straight sinus. It is needless to enumerate or trace the several sinuses. 
There are, however, two or three points in connection with the venous 
circulation of the brain, which are important. These are : first, that the 
cerebral and cerebellar veins all converge, directly or indirectly, to the 
lateral sinuses, and that hence all or nearly all the blood from these parts 
is returned by the internal jugular veins ; second, that the ophthalmic 
vein, which has almost exactly the same distribution as the ophthalmic 
artery, empties itself into the cavernous sinus on the one hand, and on the 
other anastomoses with the branches of the fascial and other veins and, 



PATHOLOGY. 



831 



third, that the longitudinal sinus communicates with the veins on the ex- 
terior of the skull through the parietal foramen, and the lateral sinuses 
with those of the head and neck through the mastoid foramina. 

B. Pathology. 

Most diseases of the nervous system may affect any part of that system ; 
and hence, although in many cases producing symptoms indicative of their 
specific nature, they tend also to evoke symptoms referable to the particu- 
lar regions of the nervous organism which they involve, and to the degree 
and manner in which they involve them. As regards the last point, it is 
obvious that here as elsewhere the functions of parts may be impaired, 
exalted, or perverted. And as regards locality, it is clear that disease 
may involve some portion of the motor tract, some portion of the co-ordi- 
nating tract, or some portion of the sensory tract ; that it may be seated 
either in the peripheral nerves, in the cord, or in the intra-cranial centres ; 
and that the symptoms will vary accordingly. Further, if the supreme 
centres be involved, there will be not only pathological sensory or motor 
phenomena, but also phenomena referable to the intellectual and emotional 
functions. We proceed to discuss some of the more important phenomena 
which are dependent on the situation of the parts affected, and on the 
degree and manner of their involvement. 

1. Motor Paralysis. Paresis. 

By the term ' paralysis' is meant the more or less complete loss of that 
power which the different motor centres should exert over the movements 
of the muscles. The term ' paresis' is often used of the slighter forms of 
this condition. Paralysis of the voluntary muscles, to which alone we 
now confine our attention, may vary from the slightest degree of impair- 
ment of voluntary power over them to that condition in which every trace 
of such power has disappeared, and the part affected is absolutely motion- 
less and incapable of motion. The quality, also, of this paralysis varies 
in different cases. In some, as in general paralysis of the insane and dis- 
seminated sclerosis, the enfeebled muscles become tremulous under the 
attempt to use them ; more commonly, as in most cases of ordinary hemi- 
plegia, their movements are slow, weak, and halting, but uniform. In 
some cases the paralyzed muscles retain their normal bulk, in some they 
waste. Sometimes they are flaccid, sometimes they preserve their natural 
tonicity, sometimes they are rigid and perhaps contracted. In some cases, 
again, they more or less completely lose the power of reacting to faradism 
or other forms of irritation ; while occasionally their contractility remains 
unimpaired or even becomes increased. And, lastly, in different cases the 
electro-sensibility of the affected muscles becomes weakened or exalted, or 
remains unaffected. 

a. Cerebral paralysis — i. General paralysis seldom occurs excepting in 
association with insanity, and is then due, as might be supposed, to some 
general impairment of the surface of the brain. It is for the most part 
slight in degree, and indicated by feebleness, not only of the muscles of the 
limbs, but of those of the trunk, head, and neck, and of those of expression, 
mastication, and deglutition. Further, as has already been pointed out, 
the muscles are usually slightly tremulous when put into action. 



832 



DISEASES OF THE NERVOUS SYSTEM. 



ii. Hemiplegia, or paralysis limited to the distribution of the motor 
nerves of one side of the body, is due as a rule to disease of the opposite 
cerebral hemisphere, corpus striatum or crus. Its most common cause 
probably is disease implicating the corpus striatum or the white matter 
immediately external to it ; and it is in such cases that hemiplegia presents 
its typical characters. The paralysis, as has been observed, is limited to 
the opposite side of the body ; but it does not affect the whole side uni- 
formly ; for while some nerves are almost always affected in a greater or 
less degree, others almost invariably escape or suffer very lightly. Those 
which escape are such as act in association with corresponding nerves of 
the opposite side, whose combined actions we cannot voluntarily restrain, 
and whose nuclei are probably (as Dr. Broadbent suggests) more inti- 
mately connected with one another than are the nuclei of other symmet- 
rically placed nerves, and are hence influenced in a greater degree than 
these by motor impulses which descend from the other side of the brain. 
The third, fourth, and sixth nerves seldom if ever suffer, so that the mo- 
tions of the eyeball on the affected side continue, for the most part, perfect. 
Again, the motor-root of the fifth nerve suffers, as a rule, but little. The 
portia dura, on the other hand, generally is distinctly though slightly and 
unequally involved ; thus the face is usually more or less blank on the 
affected side, the muscular wrinkles more or less effaced, the mouth drawn 
to the opposite side, the eye a little more open than its fellow, and winking 
somewhat laggingly performed ; nevertheless the eye can generally be per- 
fectly closed, and some power of movement remains in the whole of the 
side of the face, but more especially in its upper half. The hypoglossal is 
almost invariably markedly involved, and the tongue consequently is pro- 
truded with its tip pointing towards the paralyzed side. The motor fibres 
of the par vagum, and the motor roots of the spinal nerves going to the 
muscles of the head and neck and trunk, suffer but little ; and hence the 
patient as a rule has no difficulty in deglutition, in phonation, in maintain- 
ing the due position of his head, in respiration, or in acts needing the em- 
ployment of the muscles of the abdomen or back. The nerves of the arm 
and leg are always chiefly affected. If the case be severe both limbs are 
alike motionless ; but it is a curious fact that if there be a difference 
between them it is generally that the leg retains a greater degree of motor 
power than the arm, that it is the last to fail, the first to recover. But 
the distribution of paralysis is liable to variation, and occasionally the leg 
escapes wholly, occasionally it is affected in a higher degree than the arm. 

Disease situated in the substance of the hemisphere is also generally 
attended with hemiplegia ; especially disease occupying the frontal or 
parietal lobe. And it is in such cases that our diagnosis of the seat of 
mischief and the cause of mischief may be aided by the facts which have 
already been discussed, with regard to the localization of function in the 
gray matter of the convolutions, and the areae of distribution of the cere- 
bral arteries. If the hemiplegia be attended with aphasia we may assume 
that either the posterior part of the third frontal convolution, or else the 
wedge of white matter extending thence to the corpus striatum, is involved. 

When the lesion is situated in the crus cerebri, together with hemi- 
plegia of the opposite side of the body, there will probably be paralysis of 
the third nerve of the same side. 

b. Bulbar paralysis — When paralysis arises from disease of the medulla 
oblongata or pons Varolii, it is obvious, from the abundance and close 
proximity of important nerves and nerve-nuclei in these organs, and from 



PARAPLEGIA. 



833 



the fact that the sensory and motor strands from both cerebral hemi- 
spheres here meet and blend, that such one-sided limitation of paralysis as 
occurs in hemiplegia is scarcely likely to be present, and that if there be 
general paralysis it must differ largely in its details and in its danger to life 
from that which has before been adverted to. It is mainly in such cases 
that what is called cross paralysis is met with — paralysis, that is to say, 
of one side of the body and of the opposite side of the face. It is in such 
cases, again, that we sometimes find paralysis of both arms and legs, or of 
one arm and both legs, or the converse. And, moreover, it frequently 
happens, for obvious reasons, that there is more or less paralysis of the 
muscles of one or other or both eyeballs, or of one or other or both facial 
nerves ; or that there is difficulty of articulation, phonation, mastication, 
deglutition, or respiration, or of control over the rectum and bladder; or 
that a greater or less number of these paralyses occur in combination. It 
must be recollected, in reference to these cases, and equally in reference 
to diseases involving the under surface of the brain, that, together with 
the opposite or hemiplegic paralysis due to involvement of nerve-tissue 
above the nerve-nuclei, we are always apt to have paralysis, generally of 
the same side, due to the direct implication of nerve-nuclei, or of nerves 
after their emergence from their nuclei. It is by this circumstance that 
cross paralysis is to be explained. The great danger to life which, as is 
well known, attends disease of the parts now under consideration is due 
mainly to paralysis of the nerves supplied to the organs of deglutition, 
respiration, or circulation, which is almost invariably present in a greater 
or less degree. 

c. Spinal paralysis. Paraplegia — When paralysis is due to disease 
of the spinal cord, it generally goes by the name of paraplegia, and is 
specially characterized by the fact that the paralysis involves only the 
muscles supplied by those nerves which are given off from the cord at and 
below the seat of disease. The symptoms will of course vary, both with 
the situation and with the extent of the lesion. Thus if it involve the 
whole. thickness of the cord high up in the neck above the origin of the 
phrenic nerves, there will be complete motor paralysis of all parts seated 
below — of the arms and legs, as also of the diaphragm and other respi- 
ratory muscles. If it be situated at or above the cervical enlargement, 
the movements of the diaphragm will be unaffected, but the arms and legs 
will be paralyzed as in the former case. If the dorsal region of the spine 
suffer, the arms will necessarily escape, and the paralysis will be limited 
to the lower extremities and to just so much of the lower part of the 
trunk as is supplied by nerves given off below the seat of mischief. In all 
such cases there is more or less interference with the functions of micturi- 
tion and defecation. If the disease be seated high up, as in the cervical 
or upper dorsal region, there is difficulty in the act of micturition, owing 
to spasms of the sphincters; if, on the other hand, the disease be situated 
in the lower dorsal or lumbar region, the sphincters are paralyzed, and the 
urine runs away. The bowels are usually constipated, and defecation is 
performed involuntarily. It need scarcely be added that in complete 
paralysis sensation as well as motion is annulled. 

But paralysis below the seat of lesion is not necessarily complete. In 
many cases where it is due to pressure, or to disease of the surface of the 
cord, or of the structures which surround it, sensation remains perfect, or 
nearly so, while motorial power is wholly lost. In many cases, again, the 
paralysis, though involving all parts below equally, involves them only to 
53 



834 



DISEASES OF THE NERVOUS SYSTEM. 



the extent of impairing their power of motion. Further, many cases are 
met with in which the disease implicates unsymmetrically certain defined 
tracts only of the cord. The consequences are often very remarkable. 
If one lateral half be diseased in its whole horizontal extent, but to a 
limited extent vertically, complete paralysis necessarily involves all the 
motor nerves given off from the cord on the same side as the lesion, but 
below it, in consequence of the lesion having cut off all direct connection 
between them and the brain above. But, inasmuch as the decussation of 
the sensory nerves takes place in the cord itself immediately after their 
entry into the cord, it follows that the sensory nerves associated with the 
paralyzed region remain unaffected, while those of the corresponding region 
of the opposite side of the body share the fate of the motor nerves of the 
diseased side. Hence arise : paralysis with retention of normal sensation 
on the one side ; anaesthesia, with perfect power of motion, on the other 
side ; and in some cases a more or less distinct line of anaesthesia forming, 
on the side of lesion, the upper limit of the region of motor paralysis. 
Perfect unilateral limitation of disease is of course rare ; it is more usual 
to find one side involved in a portion only of its horizontal extent, or both 
sides involved more or less, and in unequal degrees ; under which circum- 
stances the resulting paralytic phenomena are of course less typical, and 
irregularly distributed. 

It is a curious fact, which will hereafter be more fully considered, that 
certain forms of disease have a remarkable tendency to involve particular 
regions or strands of the cord, and to be limited to them. The parts to 
which particular reference is here made are the posterior columns, the 
lateral columns, and the groups of large or motor cells in the anterior 
cornua. When disease affects the posterior columns only, or, as Charcot 
points out, the outer bands of these columns which abut directly on the 
inner aspects of the posterior cornua and the roots of the sensory nerves, 
the condition known as locomotor ataxy, or, in other words, loss of co- 
ordinating power, and not ordinary motor paralysis, involves the voluntary 
muscles of all those parts which are below the seat of disease. In a large 
proportion of cases the legs alone suffer, but the arms and even parts above 
the arms are all liable to become implicated. Inco-ordination is shown : 
partly by loss of the muscular sense, in virtue of which the patient is 
unable to judge of the amount of force needed to accomplish definite re- 
sults, and unable therefore (especially if his eyes be closed) to determine 
the position of his affected limbs in relation to other parts of his person or 
to surrounding objects ; and partly by want of control over his voluntary 
movements, which are consequently more or less violent than necessary, 
and involve a larger or smaller number of muscles than are suitable for 
their execution. There is not, however, any necessary loss of muscular 
strength, and the affected limbs sometimes retain extraordinary power. 
When the lateral columns only are the seat of disease, or more particularly 
the white matter which lies behind the horizontal line drawn laterally 
through the median canal, motor paralysis ensues in all those parts which 
are situated below the seat of lesion ; but under these circumstances, ac- 
cording to Charcot, the muscles of the affected limbs tend to get, not only 
paralyzed, but at first tremulous and ultimately more or less rigid and con- 
tracted. If the groups of large cells in the anterior cornua are diseased, 
then only the nerves which take their origin in them, and those muscles 
which these nerves supply, suffer: the muscles become paralyzed, and in a 
large number of cases speedily lose their faradic contractility, and waste. 



CONDITION OF MUSCLES IN PARALYSIS. 



835 



d. Nerve paralysis. — In the foregoing account we have considered more 
especially those forms of paralysis which are due to disease occurring above 
the nuclei of origin of the paralyzed nerves. We have, however, referred 
here and there to the fact that paralysis may be caused by disease involv- 
ing either these nuclei, or the nerves after their emergence from them. 
We have, indeed, in considering paralysis due to disease originating within 
the brain or cord, been almost compelled to advert to the fact that, when 
certain parts, more especially the pons, medulla oblongata, base of the 
brain, and spinal cord, are affected, the paralysis which ensues is neces- 
sarily apt to be compounded of paralysis due to the cutting off of the con- 
nection between nerve-nuclei and the higher centres, and of that dependent 
on direct implication of nerve-nuclei or nerves. Paralysis from destruction 
of a nerve or of its nucleus of origin, is necessarily of very limited distri- 
bution ; it affects a single muscle or a group of muscles, as, for example, 
the external rectus of one eye, or the superior oblique, or the other mus- 
cles of the eyeball together with the levator palpebral, or the muscles of 
expression of one side of the face, or certain muscles of the head and neck, 
trunk, or extremities. It also tends soon to become absolute. It is not, 
of course, denied that other varieties of paralysis are often absolute ; but, 
as we have pointed out, in ordinary well-marked hemiplegia certain nerves 
appear to escape implication, and certain others, such as the portio dura, 
become involved only to a slight extent. In primary paralysis, however, 
of the portio dura, the paralysis of the muscles which it supplies is for the 
most part general and complete. Further, the paralyzed muscles usually 
rapidly lose the power of responding to the faradic stimulus, and at the 
same time grow flaccid, and waste. 

e. Disease of the cerebellum Diseases of this part are, no doubt, often 

attended with loss of sight, and with hemiplegia ; but these phenomena 
are accidental accompaniments of cerebellar lesions, and due either to the 
direct implication of some neighboring part, or to pressure exerted by the 
diseased cerebellum on the adjoining quadrigeminal bodies or subjacent 
medulla oblongata. The usual and natural result of cerebellar disease is 
a staggering gait like that of a drunken man, or in extreme cases a total 
inability to stand or walk ; in consequence, not of muscular debility or 
mere inco-ordination of the movements of the lower extremities as in tabes 
dorsalis, but of a general impairment or loss of the power of maintaining 
equilibrium. Nystagmus and parallel deviation of the optic axes are also 
liable to occur in affections of the cerebellum. 

/. Condition of muscles in motor paralysis, i. Tone. — In some cases 
of paralysis the muscles retain their normal tonicity ; in some they get 
limp and flaccid ; in some they become rigid and contracted. The normal 
tonicity is preserved in a large number of cases of both cerebral and spinal 
paralysis. It is essential, indeed, for its conservation that the connection 
between the muscles and the cord remain intact. Limpness of muscles 
not unfrequently attends those cases of paralysis of the same centres in 
which the affection which causes paralysis is sudden in its onset and ex- 
tensive ; it generally also soon becomes developed in those muscles whose 
nerve-nuclei are directly implicated, and in those whose connection with 
these nuclei is interrupted. Rigidity or contraction of the muscles in 
cerebral or spinal disease is often the consequence of some irritation, in- 
flammatory or other, going on at the seat of disease. It is then to be 
regarded as an acute condition, and generally comes on early. But 
rigidity, with more or less contraction, is apt to ensue gradually in cases 



836 



DISEASES OF THE NERVOUS SYSTEM. 



of old paralysis ; sometimes, in the case of atrophied muscles, from their 
gradual and slow longitudinal contraction ; more frequently, perhaps, in 
consequence of secondary degenerative changes going on in the lateral 
columns of the cord. 

ii. Contractility and irritability. — The contractility of muscles under 
the influence of the faradic stimulus remains unimpaired in many cases of 
paralysis. In some cases, however, it becomes exalted, in some diminished, 
or annulled. Contractility is for the most part retained both in cerebral 
and in ordinary spinal paralysis ; but in both, and more especially in the 
latter, it is not unfrequently exalted, so that the paralyzed muscles are 
more readily thrown into contraction by a weak current than are the mus- 
cles which are still healthy. Loss of faradic contractility usually takes 
place to some extent in the muscles of paralyzed limbs which have been 
long disused, in consequence simply of their disuse ; and when atrophic 
or degenerative changes are going on in muscles their contractility is 
necessarily impaired at least proportionately to the amount of injury or 
destruction that has taken place. The most remarkable instances, how- 
ever, of such loss are those in which the paralysis is due to disease involv- 
ing either the nerve-nuclei or the nerves connected with the affected 
muscles. In some of these cases the loss of faradic contractility is marked 
and rapid, and not unfrequently it becomes totally abolished in the course 
of from five to ten days. It is important to note, however, that the gal- 
vanic current acts in a very different way to the faradic current ; that when 
slowly interrupted it acts far more powerfully on many paralyzed muscles 
than on healthy muscles ; that in the cases just adverted to, attended with 
rapid loss of faradic contractility, readiness to respond to the slowly in- 
terrupted galvanic current increases with the disappearance of the former; 
and that at length even a feeble galvanic current will often readily evoke 
contraction in muscles which have become wholly irresponsive to faradism. 

iii. Faradic sensibility — This condition (provided complete anaesthesia 
do not attend the muscular paralysis) is generally augmented with augmen- 
tation of muscular contractility, and diminished with the diminution of that 
property. But occasionally, as for example in hysteria, contractility re- 
mains when muscular sensibility has disappeared ; while, on the other 
hand, it now and then happens that sensibility continues after the muscles 
have almost entirely ceased to contract. 

iv. Nutrition In a considerable number of cases paralyzed muscles 

retain their bulk and texture, or at most become slightly impaired in these 
respects, as even non-paralyzed muscles are apt to do, from mere disuse, 
and hence remain in a condition to take on active duty so soon as the 
cause of paralysis disappears. This is generally the case when the cause 
of paralysis lies above the nuclei of origin of the paralyzed nerves. In 
these cases, also, the muscles generally retain their tone and faradic con- 
tractility little or not at all impaired. When, however, the motor nuclei 
or nerves emanating from them are the seat of disease, rapid muscular 
emaciation usually takes place concurrently with loss of faradic contrac- 
tility. To this subject we shall subsequently recur. 

v. Reflex action. — Involuntary movement of paralyzed muscles, in 
obedience to reflex irritation, is a phenomenon of common occurrence. 
The most striking forms of reflex action occur in cases of spinal paralysis, 
in which some circumscribed lesion cuts off all nervous connection between 
the brain and paralyzed limbs, leaving the portion of cord with which these 
are connected in a healthy condition. In such cases, sometimes under the 



CONDITION OF MUSCLES IN PARALYSIS. 



837 



influences of defecation or micturition, sometimes from the irritation of 
bedclothes, but more strikingly from touching or tickling the soles, the 
paralyzed limbs may be made to execute violent and repeated movements. 
When one sole is irritated the corresponding limb may be made by suc- 
cessive efforts to become powerfully flexed at the hip, knee, and ankle- 
joints, while the toes are widely separated and extended. In most cases 
these reflex movements are limited to the irritated member ; but in some 
instances both limbs become involved, and occasionally the muscular con- 
tractions are still more widely distributed. Similar reflex phenomena may 
generally be excited in the paralyzed limbs of hemiplegic patients. It is 
obvious that reflex phenomena can arise only where the connection be- 
tween the paralyzed muscles and the nerve-centres of the cord are main- 
tained, and that hence they can never be present in parts whose paralysis 
is due to the destruction of nerves or nerve-nuclei. A phenomenon ref- 
erable to the same class is sometimes observed in patients suffering from 
cerebral paralysis, namely, the sudden movement of a paralyzed limb or 
of certain groups of paralyzed muscles under the influence of emotional 
excitement. 

[Attention has recently been directed by Westphal and Erb to a class 
of symptoms which they have described under the name of tendon reflexes, 
and which is of the greatest importance in the diagnosis of diseases of the 
spinal cord. If in health, a tendon, as for instance the tendon of the 
quadriceps and the ligament of the patella, or the tendo Achillis be tapped 
with the finger, or lightly struck with the percussion hammer, the muscle 
or group of muscles connected with it will immediately contract. The 
same effect is produced, but in a much less degree, when the tendons of 
the smaller muscles are struck, being in some cases, however, scarcely 
noticeable. This contraction, which is reflex in character and not the 
direct result of the blow upon the muscle itself, is exaggerated in certain 
diseases, and diminished or even abolished in others. In the former case 
the lightest tap on the large tendons will be followed by most vigorous 
jerking of the limbs, and distinct contractions will be excited by it in those 
muscles in which little or no appreciable effect is usually produced. The 
phenomenon may often be demonstrable in cases in which no reflex move- 
ments can be excited by irritation of the skin. On the other hand, the 
reflex action of the skin may be exaggerated and the tendon reflexes 
diminished — or both may be increased or diminished together. There 
would seem, therefore, to be no necessary relation between them. 

Of very similar nature is another symptom to which the name of "ankle 
clonus" has been given. This consists of a convulsive tremor of the mus- 
cles of the leg, which occurs in certain diseases when the foot of the 
patient is rapidly and forcibly flexed by another person, and which con- 
tinues as long as the hand of the operator remains in contact with the foot. 
Indeed, in extreme cases, it is sufficient for the patient himself, when in a 
sitting position, to touch the floor with his toes, for it to be produced in 
the greatest perfection. When developed in the highest degree it extends 
to the whole leg and then to the other leg, and is generally most marked 
in cases in which the tendon reflexes are exaggerated. In order to avoid 
repetition as much as possible, these symptoms will be referred to specially 
in the description of those diseases only in which they are increased. 
The diseases in which they are diminished or abolished are tabes dorsalis, 
infantile paralysis, and probably also progressive muscular atrophy and 
paralysis agitans.] 



838 



DISEASES OF THE NERVOUS SYSTEM. 



2. AncBsthesia. 

Anaesthesia, or impairment or loss of sensation, may, like motor paralysis, 
exist in various degrees, and occupy various regions of the body. It may 
be limited to the skin or muscles, or may involve the whole thickness of 
the part affected. The last variety is the most common. In its slighter 
degrees it is often attended with more or less tingling, pricking, formica- 
tion, or sense of numbness ; and the affected part, in relation to things 
with which it is brought into contact, feels to the sufferer as if protected 
or covered by some thick soft texture. If his hands be the seat of anaes- 
thesia, they seem as if clothed with thick gloves ; if his feet, as if he were 
walking on cotton-wool or other soft yielding material. In extreme cases 
the skin and subjacent parts are wholly insensible to external impressions, 
and admit of being pricked, cut, burnt, or otherwise injured without the 
knowledge of the patient. In most cases abeyance of ordinary tactile 
sensibility is attended with similar abeyance of the capacity for distin- 
guishing painful impressions, and heat and cold ; but this is not always the 
case, for now and then the capability of recognizing these latter impres- 
sions appears to survive in some degree when the capability of distinguishing 
the former is wholly lost — a fact which has led some physiologists to 
believe that these different forms of sensation travel to the sensorium by 
different routes. Muscular sensibility is sometimes impaired or lost in 
cases of paralysis while the cutaneous sensibility remains unaffected; and 
occasionally in hysterical cases muscular insensibility, with or without 
cutaneous anaesthesia, goes along with unimpaired muscular contractility. 

There are a few other points connected with anaesthesia which claim 
attention. The first of these is the fact that persons suffering from anaes- 
thesia often experience subjective sensations referable to the anaesthetic 
regions, and not unfrequently complain of neuralgic and other pains in 
them ; the second is that sometimes, when sensation is greatly impaired, 
the patient does not take cognizance of impressions made on the affected 
part until after the lapse of a few seconds, or it may be as much as half a 
minute — the impression appears to be delayed in its transmission to the 
sensorium ; the third is the fact that under similar conditions there is often 
a peculiar difficulty in distinguishing between the characters of different 
impressions; the last to which we shall refer is the circumstance that, inas- 
much as it is through the sensory or afferent nerves that reflex motor 
phenomena are excited, it is obvious that if the disease causing anaesthesia 
exist in the course of the nerve or in its nucleus, no irritation of its ex- 
tremity can evoke reflex action, while if it be due to spinal disease, the 
probability is that irritation of the extremities of the anaesthetic nerves 
given off below the seat of disease will excite muscular action in the cor- 
responding muscles. Similar phenomena to the last, but of a more com- 
plicated character and higher order, are not unfrequently produced through 
the agency of the nerves of sight and hearing. 

Anaesthesia, equally with motor paralysis, may depend on disease of the 
brain, disease of the medulla or other parts at the base of the brain, disease 
of the cord, or disease of nerves. 

a. Cerebral a?icesthesia — i. General impairment of sensibility may at- 
tend the general paralytic condition which is associated with a special 
form of insanity. 

ii. Hemi-ancesthesia may arise, like hemiplegia, from disease of one of 
the cerebral hemispheres or the ganglia or crus immediately connected 



ANAESTHESIA. 



839 



with it. It is, however, of much less common occurrence than hemi- 
paralysis, and rarely occurs independently of it. Experiments on the 
lower animals and pathological observation concur to prove : that the optic 
thalamus has the same kind of relation to sensation (hat the corpus striatum 
has to motion ; and that lesion of this part is attended with anaesthesia of 
the opposite side of the body. As a matter of fact, however, hemi-anaes- 
thesia is generally due to lesion, not of the optic thalamus, but of the 
external capsule in relation with the optic thalamus, or of that portion of 
the commencement of the corona radiata which contains the fibres of com- 
munication between the optic thalamus and corresponding cerebral hemi- 
sphere. Cerebral hemi-anaesthesia, unlike cerebral motor paralysis, is for 
the most part universal throughout the affected side : and in connection 
with it there is frequently if not generally anaesthesia of certain of the 
nerves of special sense — deafness of the corresponding ear, loss of taste on 
the corresponding side of the tongue, and especially loss of sight in the 
corresponding eye. As regards loss of sight in the eye opposite the 
cerebral lesion it may be observed that this seems to occur when the lesion 
implicates the internal capsule. A case of Dr. Jackson's would seem to 
show that disease of the optic thalamus itself tends rather to cause hemiopia 
of both eyes. True smell is probably lost on the same side as the cerebral 
lesion ; but tactile anaesthesia of the nostril occurs on the anaesthetic side. 

Theory, and to some extent experience, would lead us to believe that 
disease affecting the temporo-sphenoidal and occipital lobes, and the poste- 
rior part of the parietal lobe, would be more likely to be attended with 
anaesthesia, than with motor-paralysis, of the opposite side of the body. 
And in connection with this subject it is important to recollect the position 
of Ferrier's centres of vision, hearing, smell, taste, and touch. 

Affections involving the tegmentum of the crus would of course be at- 
tended with more or less marked hemi-anaesthesia of the opposite side. 

Hemi-anaesthesia is in some cases absolute — the patient feels nothing. 
But more frequently it is incomplete — he feels generally in some degree ; 
or he retains more or less sensation in certain parts, especially the palm or 
sole, or certain areae of the leg or forearm ; or, as occasionally happens, 
the affected side is irregularly studded with anaesthetic patches. Not u in- 
frequently patients who are incompletely hemi-anaesthetic experience con- 
siderable pain when their paralyzed limbs are moved, and refer the sensa- 
tion due to pricking and other forms of pain inflicted on them to a joint 
or some other part remote from the seat of injury ; and at the same time 
wholly misconceive the character of the impression. 

b. Bulbar ancesthesia When disease involves the pons or medulla 

oblongata, some degree of anaesthesia is very apt to be associated with 
motor paralysis, and like it to be of irregular distribution. Of course all 
the sensory nerves which take their origin in these parts are, like the motor 
nerves, liable to be implicated. 

c. Spinal ancesthesia Anaesthesia from spinal disease, like that from 

cerebral disease, is far less common than the corresponding paralytic- 
affection, and is rarely met with apart from it. There are several reasons 
for this : the sensory tracts of the cord are limited almost exclusively to 
the posterior cornua, and the rest of the gray matter behind the central 
canal, so that they are apt to escape pressure and the other consequences 
of disease occupying the periphery of the cord or the surrounding tissues ; 
moreover, it seems to be proved by experiment that a narrow thread of 
gray matter is sufficient to maintain an effective connection between the 



840 



DISEASES OF THE NERVOUS SYSTEM. 



sensory tract below and that above. Disease limited to the central region 
of the cord, or rather to its posterior part, might conceivably induce anaes- 
thesia without paralysis. We have previously pointed out the important 
fact that disease of one lateral half of the spinal cord, interrupting the 
longitudinal continuity of the fibres, causes anaesthesia of the opposite side 
of the body. 

d. Nerve ancesthesia Local anaesthesia, like local paralysis, may arise 

from disease affecting either a sensory nerve or its nucleus, and thus neces- 
sarily occupies the same side of the body as that on which the lesion ex- 
ists. Such anaesthesiae are not unfrequent in the area of distribution of 
the fifth pair or some of its branches, or in that of one or other of the 
spinal nerves. The anaesthesia which forms the upper boundary of the 
paralyzed region in cases of unilateral injury or disease of the cord is a 
typical example of this condition. The nerves of special sense may suffer 
equally with those of common sensation. 

3. Convulsions. Spasms. 

In speaking of paralysis, we have referred to the facts, that associated 
with this state it is not uncommon to observe tremulousness of muscles 
arising especially during voluntary efforts, and that paralyzed muscles oc- 
casionally become rigid and contracted. It may be added that convulsive 
movements of various kinds are not unfrequently associated with paraly- 
sis. They more frequently occur, however, independently of it. 

Convulsions may affect single muscles or portions of muscles, groups of 
muscles, a limb, the head and neck, one half of the body, or the whole of 
it. They may be intermittent or continuous, and may vary in intensity 
from a scarcely perceptible flickering of the muscular fibres, to contrac- 
tions of such violence and strength that the muscles become ruptured. 
Intermittent contractions are termed clonic, persistent contractions tonic. 

The slighter forms of convulsions are exemplified in the tremulous, more 
or less rhythmical, movements which are observed under many various con- 
ditions, and generally cease during sleep. Some of these attend efforts at 
voluntary movement only, and are then usually regarded rather as evidence 
of debility than as convulsions in the true sense of the term, on the ground 
that they depend on the intermittent transmission of voluntary impulses 
only. In true convulsions there is a similar intermittent transmission, but 
the force is exerted independently of and beyond the will. This distinc- 
tion is useful to be borne in mind, but it is one that is not always available 
in practice, if indeed the two conditions do not frequently run into one 
another. Among the convulsions which on the above view might be re- 
ferred to debility are the fibrillar tremblings of the lips and tongue of 
patients suffering from general paralysis during their attempts to speak, 
and the irregularly rhythmical movements of the limbs which not unfre- 
quently attend the voluntary efforts of those laboring under disseminated 
sclerosis of the nerve-centres ; among those which are truly convulsive 
may be enumerated that flickering of the orbicularis palpebrarum which 
is known by personal experience to all, the general tremulousness which 
attends exposure to cold and febrile rigors, the subsultus tendinum of pa- 
tients in the typhoid condition, the more or less general rhythmical tremors 
of paralysis agitans and chronic mercurial poisoning, and the tremors which 
occasionally attack the lower extremities of paraplegic patients. 

Another form of convulsion is that to which the term choreic may be 



CONVULSIONS. SPASMS. 841 

applied, and of which chorea furnishes the most typical example. In this, 
as in the former series, the movements cease during sleep, and as in the 
paralytic form of trembling are greatly aggravated during voluntary efforts 
and under mental excitement. Choreic movements are characterized 
mainly by their abruptness and irregularity, and by the fact that when 
they are engrafted on any voluntary movement they interrupt its progress 
by a series of grotesque contortions and diversions which are not then 
necessarily limited to the limb or organ which is making the effort. Cho- 
reic movements are not unfrequently hemiplegic or even limited to a limb. 
Related in some degree to chorea are the grimaces and other tricks of 
movement to which some persons acquire an uncontrollable impulse ; the 
peculiar rotatory and other rhythmical or irregular motions to which hys- 
terical females are occasionally addicted ; and especially perhaps the redun- 
dant and awkward movements of locomotor ataxy. A peculiar form of 
convulsion also related to chorea has been described by Dr. Hammond 
under the name of 'athetosis.' It is characterized mainly by continued 
slow movements of the fingers and toes, and inability to maintain them in 
any position. It generally ceases during sleep, and supervenes on hemi- 
plegia, in which more or less complete recovery of motor power has taken 
place. 

The clonic convulsions of epilepsy and epileptiform conditions are 
characterized by more or less violent and rapidly repeated alternating 
movements — rapidly repeated alternate flexions and extensions of the arms 
or legs, jerkings of the head and neck, or similar movements of the muscles 
of the face or eyes. These, like choreic convulsions, are not unfrequently 
unilateral, but they may be general, or limited to a single limb or to part 
of a limb. 

In tonic spasm or convulsion, muscular contractions take place, which 
are more or less enduring. It can readily be understood that the terms 
clonic and tonic can be employed only in a relative sense, and that clonic 
and tonic spasms pass into one another by insensible gradations. Tonic 
spasms are exemplified in the cramps which occur, after fatigue, in the 
muscles of the calf, or in various muscles in Asiatic cholera ; in the con- 
traction of the limbs which takes place in the course of some forms of 
paralysis ; in the folding of the thumb into the palm, the gradual drawing 
up of the arm, or other comparatively slow and strong contractions of 
muscles, which are usually the earliest of the convulsive phenomena of 
the epileptic fit; and in the violent attacks of muscular rigidity which, by 
their repetition constitute the characteristic sign of tetanus and strychnia 
poisoning. 

It is not always easy to localize the seat of the diseases causing convul- 
sions. In reference, however, to this point, it must be recollected that all 
those parts which by their destruction cause paralysis of certain regions, 
are necessarily likely under irritation to cause motor phenomena in the 
same regions. Thus, since hemiplegia is determined only by destructive 
disease of the opposite cerebral hemisphere, corpus striatum or cms cerebri, 
it may be taken for granted that convulsions affecting generally one side 
of the body must be caused by disease of the same parts. It is probable 
on this ground (but not on this alone) that choreic and epileptic convul- 
sions, which are frequently unilateral, are of cerebral origin. Again, 
since paraplegia depends on disease affecting the cord, there is reason to 
suspect that convulsive affections presenting a similar arrangement are of 
spinal origin. Tetanus and strychnia poisoning are cases in point, although 



842 



DISEASES OF THE NERVOUS SYSTEM. 



it must be admitted that in both cases the lesion involves the medulla ob- 
longata even more importantly than the cord. When a single muscle or 
group of muscles is affected, we must look to the origin of the nerve or 
nerves which supply it; and it is clear that, theoretically, the lesion 
might be referred, either to the nucleus of the nerve, or to a limited 
spot in the corpus striatum or in the gray matter of the cerebral convo- 
lutions in direct linear continuity with the nerve-nucleus. It may be 
observed, however, that the simpler and more restricted in area such 
limited convulsion is the more likely is it to be due to the influence of 
the nerve-nucleus ; the more complicated and, so to speak, purposive, the 
more likely is it to be traceable to the action of the corpus striatum or cere- 
bral convolutions. 

The recent observations with regard to the intimate association be- 
tween certain areas at the surface of the brain and certain groups of mus- 
cular movements have a special importance in relation to the localization 
of cerebral disease attended with convulsions. It will be recollected 
that irritation of each of these centres provokes specific combinations of 
convulsive movements ; and these facts, together with Dr. Hughlings 
Jackson's, and (since his) other pathological observations on the same 
subject, demonstrate that we may in many cases determine the exatit seat 
of cerebral lesion by paying minute attention to the details of convulsive 
attacks. 

An important fact in connection with unilateral convulsive affections, 
such as chorea and epilepsy, due presumably to disease of the opposite 
cerebral hemisphere or corpus striatum, is that the convulsive movements 
are generally unilateral only in those parts, such as the arm and leg, 
which are chiefly paralyzed in hemiplegia ; while, in those parts which 
are only slightly affected, or escape wholly, in hemiplegia, convulsive 
movements are not only present, but are associated with similar move- 
ments of the corresponding parts on the opposite side. This fact con- 
firms Dr. Broadbent's hypothesis (already referred to) with respect to the 
more or less intimate connection subsisting between the corresponding 
nerve-nuclei of opposite sides. For that intimate connection which, in 
hemiplegia, would allow motor influences descending from the opposite 
healthy hemisphere to be in certain regions diffused horizontally, and 
thus to counteract paralysis, would necessarily equally allow abnormal 
motor impulses descending from the irritated hemisphere to influence in 
the same regions the motor nuclei of both sides, and thus to cause bilateral 
convulsions. 

4. Hyperesthesia. Dysesthesia. 

Augmented or perverted sensibility has the same relation to the sensory 
part of the nervous system that spasms and convulsions hold to the motor, 
and indeed the two conditions are not unfrequently associated. Hyperes- 
thesia means strictly exalted sensibility — a condition in which the various 
organs of sense are more readily affected than they should be by impres- 
sions which are made upon them, or in which the sensorium is more appre- 
ciative than natural of the impressions which are conveyed to it from the 
organs of sense. Practically, however, exalted sensibility is scarcely if 
ever distinct from painful sensibility. The hyperaesthetic eye cannot bear 
bright light, the hyperaesthetic ear is affected painfully by powerful, high, 
or discordant sounds, the hyperaesthetic skin shrinks from the slightest 



NUTRITIVE LESIONS IN NERVOUS DISEASES. 843 

pressure or from mere contact. Hyperesthesia in this sense is not uncom- 
mon ; it is frequently observed in hysteria, sometimes in the early period 
j of febrile disorders, occasionally in inflammatory and other affections of 
! the central nervous organs. It is a common feature in hemi-paraplegia, 
I in which case not only is the paralyzed side generally still sensitive, but 
I its sensibility often becomes painfully acute ; it is common, too, in inflam- 
j matory affections involving the skin. 

Under the general term dysesthesia may be included a large number 
of abnormal sensations, referable to the ordinary sensory nerves, to the 
nerves of special sense, and to the sympathetic system, or at all events to 
j the afferent nerves connected with the visceral organs. Among perverted 
sensations referable to the skin may be included sensations already ad- 
| verted to as frequently indicating the advance of anesthesia, namely, 
numbness, sense of coldness, tingling, formication, and the like ; as also 
itching, burning, cutting, stabbing, crushing, shooting, aching, constrictive 
and other pains, which are so common and arise under so many various 
conditions that it would be a waste of time to endeavor to enumerate them 
all. True neuralgic pains are usually of a shooting character, flash with 
| momentary intensity along the fibres of the affected nerve, and occur in 
paroxysms composed of momentary shocks following one another in rapid 
succession. Other varieties of dysesthesia are those which are manifested 
in relation to visceral organs, among which may be included the ' want of 
I breath,' which attends asthma and cardiac disease ; the agony of angina 
pectoris; painful thirst or craving for food; gastralgia, enteralgia ; and 
various indescribable sensations referable to different parts of the body, of 
which nervous and other patients complain, or which constitute many of 
the varieties of the so-called epileptic aura. Dysesthesia of the organs of 
special sense may be indicated by the appearance of subjective phenomena 
referable to these organs : of the eye, by the appearance of sparks or 
flames, or other objects which may even present definite forms, be endowed 
with motion, and assume the visible attributes of living objects ; of the 
ear, by the perception of sounds, such as humming, buzzing, singing, the 
ringing of bells, violent explosions, and even words and actual conversa- 
tion ; of the nose, by the perception of odors : of the taste, by the percep- 
tion of flavors. 

5. Influence of Nervous Diseases over the Nutritive Processes. 

a. Sympathetic system There is no doubt that the sympathetic system 

is largely concerned in morbid processes. We know how importantly con- 
striction of the bronchial tubes is connected with asthma; what an essential 
part contraction of the vessels plays in the production of the phenomena 
of angina pectoris, and of the anemia of the brain which, as a rule, pre- 
cedes the epileptic attack ; how largely dilatation of vessels is concerned 
in inflammation ; and also that diabetes and various other disorders have 
been attributed to dilatation of the vessels of the liver or other organs with 
consequent hyperemia of these parts. We need not, however, consider in 
detail the various pathological phenomena which are rightly or wrongly 
attributed to the influence of the sympathetic nerves. It is sufficient to 
say that these, so far as the vessels are concerned, solely determine varia- 
tions in diameter ; that, if contraction take place, less blood reaches the 
tissues, which then suffer in their functional activity, and even in their 
nutrition ; that if, on the other hand, dilatation take place, the tissues 



844 



DISEASES OF THE NERVOUS SYSTEM. 



become hyperaemic and the various physiological processes proper to them 
stimulated into unwonted activity. Still, however much the affected parts 
suffer, temporarily or permanently, in their functional attributes, it does 
not appear that their nutrition necessarily gets checked or perverted beyond 
the limits of health; the anaemic tissues do not necessarily fall into degene- 
ration or decay, the hyperaemic tissues do not necessarily pass into inflam- 
mation or pathological overgrowth. It must nevertheless be admitted that 
the hyperaemic tissues when exposed to irritation are more liable to become 
inflamed than healthy tissues are. 

b. Cerebrospinal system. — Admitting fully, however, the essential part 
which the sympathetic system plays in the regulation of the nutritive pro- 
cesses both in health and in disease, and admitting also the little obvious 
influence which the spinal system or nerves exerts over the same phenom- 
ena in health, it seems certain that it is to the spinal rather than to the 
sympathetic system that we must refer certain localized lesions which are 
apt to take place in the course of nervous disorders, and which we are now 
about to discuss. We refer more particularly to certain affections of the 
muscles, certain affections of the joints, certain affections of the skin and 
subjacent tissues, and certain affections of the viscera, especially the kid- 
neys and bladder. 

i. Muscles — We have already shown that in many cases of motor paral- 
ysis the implicated muscles retain their healthy texture, their bulk, and 
their contractility, under the influence of stimuli, and, it may be, retain 
these qualities scarcely impaired for an indefinite period; only after a 
while wasting to a slight extent from mere disuse, and possibly undergoing 
some secondary degenerative change. ' Other cases of motor paralysis, 
however (cases for the most part of acute onset), are attended with rapid 
loss of faradic contractility and concurrent acute wasting of the paralyzed 
muscles. These consequences may follow : first, on lesions of motor 
nerves; second, on affections of the cord; and, third, but much less fre- 
quently, on cerebral disease ; but they do not follow indifferently on all 
forms of disease or injury of these several parts. It is doubtful if simple 
destruction of nervous tissue, however complete, is sufficient to induce 
them ; nor have they relation to the completeness of the paralytic phenom- 
ena. They appear to be due mainly to disease or injury causing irrita- 
tion of the nervous tissue which is its seat, and especially to disease or in- 
jury involving the motor nerves or motor centres. If, therefore, muscular 
emaciation and loss of contractility be the consequences of lesions of a 
nerve, that lesion is almost certainly not a clean cut, but the result of pres- 
sure, stretching, bruising, laceration, inflammation, or implication in some 
growth ; if they accompany spinal disease they are due to disease, probably 
irritative, involving the anterior cornua, and particularly those groups of 
giant cells which are in direct relation by means of motor nerves with the 
affected muscles. No doubt many different forms of spinal affection are 
apt to be followed by muscular atrophy. Locomotor ataxy, disseminated 
sclerosis, and disease limited in the first instance to the lateral white 
columns, may each by horizontal extension involve the anterior cornua at 
certain points, and so induce irregularly distributed atrophic changes of 
the muscles; and, similarly, caries of the vertebrae, fracture of the spine, 
and tumors, may each of them, by pressure or otherwise, implicate the 
gray matter in their immediate vicinity and hence cause atrophy of the 
muscles supplied by the nerves emanating from the seat of lesion. Further, 
diffused inflammation, and hemorrhage into the substance of the cord, both 



NUTRITIVE LESIONS IN NERVOUS DISEASES. 



845 



| of which conditions may involve the central. parts of the cord in a consider- 

' able length, may result in widespread muscular lesion. But the spinal 
affections which are the most common causes of muscular atrophy are those 
which induce infantile paralysis and equivalent conditions in the adult. In 

I these the disease, which appears to be of an inflammatory nature, originates 
apparently in the groups of large cells occupying the anterior cornua, and 

I even if distributed throughout the whole length of the cord may still be 

j limited to them. When acute atrophy of muscles occurs as a sequela or 
consequence of cerebral disease, it is probably always directly referable to 
some secondary descending lesion of the cord implicating the motor nuclei 

j Post-mortem examination seems to show that, in the particular form of 
wasting of muscles here discussed, the implicated nervous tissues from the 
seat of lesion downwards (mainly in its connective-tissue elements) inflam- 
matory proliferation ; and that the initial change in the muscles is similarly 
an inflammatory hyperplasia of the connective-tissue elements and of the 
nuclei of the sarcolemma, inducing a kind of cirrhosis, to which the dimi- 
nution in size of the muscular fibres is secondary. These fibres, though 
gradually becoming more and more attenuated, seem rarely, if ever, to lose 

; their striation or to become fatty. 

ii. Joints and bones Irritative affections of nerves are sometimes fol- 

! lowed by inflammation of joints or periosteum, which may terminate in 

disorganization and necrosis. But joint-affections are also occasionally 
developed, in the course of diseases of the cord or brain, in the members 
which are paralyzed. Charcot divides these joint-affections into two groups. 
In the one the attack is acute or subacute, and attended with tumefaction, 
redness, and often more or less severe pain. In the other the attack com- 
mences suddenly, with diffused swelling of the limb, is attended with little 
or no pain, but involves the rapid erosion and disappearance of the carti- 
lages and joint-ends of bones. The former of these affections has been 
met with in paraplegia from injury to the spine or from caries, and then 
most frequently in the knee. It has been observed also in hemiplegia, and 
mainly in hemiplegia due to softening ; it then occurs usually in the joints 
of the upper extremity, which it attacks as a rule from two to four weeks 
after the occurrence of paralysis and at the time when chronic contraction 
is taking place. This affection is essentially synovitis. The other form of 
the disease has been frequently observed in persons suffering from loco- 
motor ataxy, and for the most part at the onset of the symptoms of inco- 
ordination. It usually occurs in the knees, shoulders, or elbows, and is 
attended with much effusion into the joints, rapid destruction of the joint- 
surfaces, and not unfrequently dislocation. The processes here adverted 
to are not unlike those which occasionally attend rheumatism. The diag- 
nosis, however, between joint-affections of nervous origin and those due to 
rheumatic inflammation is generally easy, if attention be paid to the limita- 
tion of the disease to the paralyzed limbs, and to the concurrence of other 
trophic changes belonging to the same class. It must be especially noted 
that the joint-affection is by no means unfrequently associated with rapid 
muscular atrophy, and that there is ample reason for believing that it is 
due to irritation of the same nerves and the same part of the cord whose 
irritation causes the muscular lesion. 

iii. Skin Various inflammatory and other nutritive changes in the skin 

and subjacent tissues have been traced to affections of the nerves and nerv- 
ous centres. It has long been recognized : that, after division of the 
branches of the fifth pair distributed to the eye and conjunctiva, inflam- 



846 



DISEASES OF THE NERVOUS SYSTEM. 



mation, leading to more or less- rapid destruction of these parts, is apt to 
occur ; and that in cases of paraplegia attended with total abolition of 
sensation, inflammation, ulceration, and gangrene are extremely liable to 
supervene in the paralyzed parts. It has been proved, however, by ex- 
periment on the lower animals, and by the results of careful attention to 
patients suffering from such lesions, that these inflammatory changes are 
not usually due to the withdrawal of any direct conservative influence 
which the healthy sensory nerves exercise over the parts to which they 
are distributed, but to the fact that the loss of sensation prevents the suf- 
ferers from recognizing the presence of mechanical irritants or other in- 
jurious influences and so from avoiding or counteracting their operation. 
Various affections, however, more or less closely related to these in their 
characters, are undoubtedly referable to the direct operation of irritative 
affections of the sensory nerves, cord, or brain. The most important of 
them may be ranged under the heads of erythema, vesicular eruptions, 
bullous eruptions, atrophic changes, and gangrene. 

Cases are not unfrequently met with in which mechanical or other inju- 
ries to sensory nerves, not necessarily attended with anaesthesia, but often, 
as might be supposed, with neuralgia, are followed by erythematous red- 
ness limited to the area? of distribution of the nerves, which redness may 
proceed to vesication, pustulation, ulceration, or gangrene. Such results 
have been observed in cases of tumor or inflammation involving the fifth 
nerve, and also in cases of injury or disease of certain of the sensory or 
mixed nerves of the arm or leg. One of the most interesting examples is 
furnished by herpes or zona, limited to the distribution of a single sensory 
nerve. Another example of great interest is afforded, as Charcot has 
pointed out, by anaesthetic leprosy — one of the special features of which 
affection is the excessive development of cellular elements in the course of 
the nerves, between the nerve-tubules. This overgrowth leads to the 
gradual destruction of the nerves and consequently to both anaesthesia and 
motor paralysis ; but it leads also to atrophic changes in the muscles, and 
(what specially concerns us now) to erythematous patches on the skin, on 
which vesicles or bullae become developed or which undergo atrophic 
changes, and in some cases to gangrenous destruction of the skin and sub- 
jacent soft tissues, and even of the bones. 

A peculiar atrophic alteration of the skin following injuries of the nerves 
of the extremities has been described under the name of ' glossy skin,' by 
Mr. Paget and Dr. S. Weir Mitchell. In well-marked cases the skin be- 
comes smooth, hairless, almost devoid of wrinkles, glossy, pink or ruddy, 
or blotched as if with permanent chilblains. The nails, too, become fis- 
sured and have a tendency to separate from their matrices. The skin thus 
altered is frequently the seat of an eruption having a close resemblance 
to eczema, and of a form of neuralgia which varies from the most trivial 
sense of heat to agonizing pain. The skin, moreover, becomes extremely 
tender. 

Trophic affections of the skin are equally apt to take place in connection 
with lesions of the cord. In locomotor ataxy, for example, according to 
Charcot, eruptions are occasionally developed, more especially during 
periods of exacerbation of the disease, and in connection with the occur- 
rence of neuralgic pains; and he points out that the eruption is not unfre- 
quently limited to the parts to which the suffering nerve is distributed. 
Among special forms of skin disease thus arising he mentions lichen, urti- 
caria, zona, and ecthyma or impetigo ; and we may add to the list erythema 



NUTRITIVE LESIONS IN NERVOUS DISEASES. 



847 



nodosum of unusual distribution. In this case Charcot attributes the 
cutaneous affection, as he does the pain, to the involvement, in the disease 
of the posterior columns, of the nerve-fibres passing through the outer 
part of these columns, previous to their emergence from the cord. Again, 
erythema in patches — which may go on to the development of vesicles 
(herpes), and thence to the formation of large bulla? (pemphigus) — is not 
uncommonly a consequence of that affection of the membranes of the cord 
termed 4 pachymeningitis,' which during its progress compresses and irri- 
tates the cord itself and the roots of the sensory nerves. A similar general 
development of bullae is sometimes met with in vertebral caries. Erythe- 
matous, vesicular, or pustular eruptions are occasionally developed in 
hemiplegic patients upon the paralyzed side of the body. 

The most important, and on that account the most interesting, of the 
cutaneous lesions consequent on paralysis are the patches of gangrene which 
are commonly known as ' bed-sores.' These are apt, of course, to form in 
many patients, whether paralytic or not, who are confined to bed, partly 
from the constant pressure to which prominent parts are under sucli cir- 
cumstances exposed, partly from the effects of the patients' secretions, 
which accumulate beneath them, and in no small degree from the neglect 
of nurses. But there are certain paralytic cases in which bed-sores form 
with remarkable rapidity — in the course of two or three days, it may be, 
from the commencement of the illness — and this without exposure to undue 
pressure, or to the irritation of urine or feces, and in spite of the most 
watchful care on the part of the attendants ; moreover, the bed-sores appear 
on the paralyzed part, and on that alone, even if the unparalyzed parts 
have been specially exposed to pressure. The bed-sores here referred to 
commence as patches of erythema, with more or less inflammatory infiltra- 
tion and congestion of the subjacent tissues, sometimes including the 
muscles and the bones. In a short time vesicles or bulla? appear upon 
them, and superficial sloughs form. These gradually extend in surface 
and depth, and may thus eventually occupy a wide area, and involve 
muscles, bones, and even implicate subjacent cavities. Such bed-sores 
may occur either in hemiplegia or in paraplegia, and on any part of the 
paralyzed surface, but they arise more especially on such parts as are ex- 
posed to pressure. In hemiplegia they rarely appear except about the 
centre of the buttock. In paraplegia they specially involve the sacral 
region, and are hence situated on a higher level than those occurring in 
hemiplegia, and occupy a more central and symmetrical site. Moreover, 
in paraplegia they are apt to appear also on the heels, inside the knees, 
and upon the hips. The form of hemiplegia which acute bed-sores tend 
specially to complicate is that due to hemorrhage. The spinal affections 
in which they more particularly occur are those in which inflammation or 
hemorrhage involves a pretty considerable extent of the central portion of 
the cord. They may hence follow fractures and other injuries of the spine 
and exacerbations or acute complications of chronic diseases. The forma- 
tion of these acute bed-sores must always be regarded as a phenomenon of 
serious import; but occasionally, of course, the morbid process becomes 
arrested, and convalescence may supervene. 

The special seat in the cord of the lesions on which the various skin 
affections which have been enumerated depend has not been so accurately 
determined as the seat of those lesions which evoke affections of the mus- 
cles and joints. There are good grounds, however, for the conclusion that 



I 

w 

848 DISEASES OF THE NERVOUS SYSTEM. 

the posterior cornua and central regions of the gray matter have the same 
trophic relation to the skin as the anterior cornua to the muscles. 

iv. Viscera The visceral affections of chief importance referable to 

spinal lesions are inflammations of the bladder and kidneys, with the dis- 
charge of purulent, bloody, ammoniacal, and fetid urine. In most cases I 
of paraplegia these conditions are apt to supervene after a time in conse- 
quence of the constant retention of urine in the bladder, and the irritation 
to the mucous surface which results from its accumulation and decomposi- 
tion. But there are certain cases of paraplegia in which the occurrence 
of these phenomena is as early as that of bed-sores, and in which, indeed, 
they take place simultaneously. The change in the quality of the urine 
and the inflammation of the kidneys and urinary passages cannot then be 
explained by simple paralytic retention or by spontaneous decomposition 
of the urine ; and there is consequently little doubt that they also are 
referable to the direct influence of the diseased spinal cord. 

Recapitulation. — It may be convenient, by way of summary, to remark : 
first, that the pathological influence of the spinal nerves, of the spinal cord, 
and more remotely of the brain, upon the production of morbid changes in 
the muscles, bones, skin, and viscera, is associated only with those lesions 
which are irritative in their effects or inflammatory ; second, that the 
lesions which immediately determine muscular and arthritic mischief are 
situated either in the course of the motor nerves or in their nuclei of 
origin ; third, that the lesions which immediately determine cutaneous, 
and probably also visceral, inflammations involve either sensory nerves or 
the gray matter of the cord posterior to the central canal, or the imme- 
diately adjoining portions of the posterior columns of the cord, or possibly 
the ganglia at the base of the brain; and, fourth, that, although the 
variously situated spinal lesions and their respective pathological conse- 
quences have been separately considered, they are necessarily not unfre- 
quently associated. 

6. Ascending, Descending, and Collateral Lesions. 

It is a fact of considerable importance, and one to which we have 
already more than once adverted, that circumscribed lesions of the brain, 
cord, and nerves tend to the production of degenerative changes either in 
the nervous tissue above them or in that below them, or in both ; and, > 
further, that, in the case of the brain or cord, there may be horizontal I 
extension. Thus apoplectic or other destruction of some portion of one 
of the cerebral hemispheres, and still more certainly similar destruction 
of the corresponding corpus striatum leads to the occurrence of degen- 
eration, which, commencing at the seat of disease, gradually extends ; 
downwards in a band-like form along the motor tract, first involving the 
corresponding crus and anterior pyramid, and thence passing to the 
opposite side of the cord and downwards mainly along the posterior part 
of the lateral white column. Again, when lesions occupy the lower part 
of the cord, they are apt to induce degenerative changes which gradually 
ascend in the posterior columns of the cord, and more especially in those 
parts of them which lie immediately on either side of the posterior median 
fissure. Further, lesions of intermediate regions of the cord are liable to j 
be followed by both ascending and descending degenerations ; the former, 
as in the last case, limited to the posterior columns ; the latter, as in the 
first case, to the lateral columns. Occasionally also foci of disease involve 



HEADACHE. 



849 



secondary changes which extend from them in the horizontal direction ; 
and similar extension would seem now and then to start from either the 
ascending or descending secondary lesions, so as to involve more and more 
of the thickness of the cord, and especially the anterior cornua and their 
motor nuclei. 

When the anterior root of a spinal nerve is divided, its peripheral 
portion (at any rate its white substance) undergoes degeneration ; while, 
if the posterior root be divided, all the peripheral part — that which still 
retains its connection with the ganglion — remains healthy, while that 
which enters the cord degenerates. It may, however, be observed that, 
consecutively to amputation of limbs, the large cells of the anterior cornua 
in relation with them have, after a considerable time, been found atrophic. 

It is obvious that the various secondary changes above described, and 
others which occur but do not as yet admit of being referred to any 
general rule, must necessarily, in many cases, induce special clinical 
phenomena, complicating more or less seriously those due to the primary 
lesion. 

7. Central and Reflex Consequences of Lesions of the Nerves. 

Not only are central lesions efficacious in the production of peripheral 
lesions, but lesions of sensory or centripetal nerves are capable of induc- 
ing central mischief, or by reflex action mischief in the area of distribu- 
tion of centrifugal nerves. It is thus apparently : that injury to sensory 
nerves induces that irritable condition of the spinal cord which forms the 
pathological basis of tetanus ; that intestinal irritation and the irritation of 
dentition cause convulsions in young children ; that certain uterine or ova- 
rian conditions are instrumental in the production of the various psychical 
and motor phenomena which characterize hysteria; that renal affections 
occasionally lead to paraplegia; and that injury to the frontal branch of 
the fifth nerve is apt to cause amaurosis. Brown-Sequard, who has de- 
voted great attention to this subject, attributes indeed to reflex influence 
almost all the consequences which are also caused by affections of the nerv- 
ous centres ; among others, various forms of paralysis, anassthesia, deafness, 
loss of taste and smell, convulsions, delirium, and coma, together with cu- 
taneous eruptions and wasting of muscles. It is perhaps needless to add 
that he, as well as others, attributes many internal inflammations to the 
influence of irritation acting reflectorially. 

8. Headache. 

Headache is a frequent attendant upon cerebral lesions, but it is still 
more commonly due to affections of remote organs, such as the stomach, 
or to neuralgic, rheumatic, or other such conditions. In whatever cause 
the pain originates, or in whatever part of the head the cause operates, it 
seems pretty obvious that the pain must be referred to the peripheral dis- 
tribution of the sensory nerves — that is, of those sensory nerves which 
have their apparent origin at the base of the encephalon, and which are 
distributed to the integuments, bones, and membranes of the brain. Thus 
some headaches are limited to one-half of the forehead and probably to 
the corresponding eye — to the area of distribution of the first branch of 
the fifth — some occupy both sides of the forehead, some affect the vertex, 
some the occipital region. Other headaches, again, appear to occupy the 
54 



850 



DISEASES OF THE NERVOUS SYSTEM. 



I 



temples, and shoot from one side to the other, others are confined to the 
neighborhood of the ear, and others seem to be generally diffused. Head- 
aches vary in character, and are variously described. Sometimes they are 
shooting, sometimes aching, sometimes throbbing, sometimes likened to a 
weight upon the top of the head, sometimes to a sense of constriction. 
They are not unfrequently associated with intolerance of light and sound, 
visual spectra, tinnitus aurium, vertigo, nausea and sickness, drowsiness 
or wakefulness, and sometimes (even if the affection be superficial and 
wholly independent of brain disease) with more or less delirium. It is in 
most cases exceedingly difficult to refer headache to its proper cause, unless 
our diagnosis be aided by the presence of distinctive associated phenomena. 
Thus pain, almost accurately resembling in all its characteristics that of 
megrim, may be induced by the simple pressure of an unyielding hat upon 
the frontal branches of the fifth pair, and immediately cured by the re- 
moval of that pressure; rheumatic neuralgia of the forehead, from simple 
exposure to a blast of cold air, is not unfrequently attended with a peculiar 
sense of drowsiness ; and in either case the pain may be so intense and 
so distracting as to lead the patient or his doctor to suspect serious disease 
of the internal parts. Dr. Hughlings Jackson remarks that frontal head- 
ache is generally referable to abdominal affections, headache at the vertex 
to cerebral disturbance, and occipital pains to disorders of the circulation, 
and more especially to anaemia. However that may be, it is certain that 
pain due to cerebral disease may, especially in the case of cerebral tumors, 
be referred to all parts of the head, and that it may exactly simulate those 
which are of less serious origin. It may be slight or intense, continuous 
or paroxysmal, and may be attended with tenderness of the scalp, or with 
various of the symptoms which have already been referred to as frequent 
accompaniments of headache. When the pain is intense, and especially if 
it be paroxysmal, it frequently causes the patient to scream out, and to sup- 
port his head with his hands. The most intense pain, which is then usually 
very limited as to its seat, is induced by the pressure of intracranial tumors 
or abscesses upon sensory nerves. 

9. Vertigo. 

Vertigo, or swimming in the head, is that condition in which a person 
suffers from a sense of falling equilibrium, of falling or of rotating, and in 
which not unfrequently surrounding objects appear to swim or oscillate 
before his eyes. It has been attempted to distinguish between that form 
of vertigo in which the patient refers the vertiginous phenomena to his 
own person, and that in which he refers them to surrounding objects. The 
distinction is, however, obviously inadmissible. Vertigo may vary from 
a mere uncomfortable sense of oscillation, such as one feels on landing 
after a sea-voyage to a condition in which the patient is quite unable to 
maintain his equilibrium, and either falls to the ground, or is compelled to 
support himself by clutching some fixed object. It maybe momentary or 
of long duration, and in the latter case is commonly attended with exacer- 
bations. It is generally more pronounced when the patient is standing or 
walking, but may come on while he is lying down, and even has his eyes 
shut. The proximate cause of vertigo is probably multiform. Vertigo is 
often, and probably accurately, referred to variation or disturbance of the 
cerebral circulation ; in proof of which view it may be observed that it not 
unfrequently attends syncope, anaemia, and loss of blood, on the one hand, 



APHASIA. 



851 



and cerebral congestion and inflammation, on the other. It is not uncom- 
monly the consequence of an unhealthy condition of the blood or of the 
presence in it of poisonous matters : as appears from its frequent occur- 
rence in inflammatory diseases and in the specific fevers. It attends epi- 
lepsy, eclampsia, and organic lesions, such as effusions of blood and tumors. 
It is frequently of eccentric origin, referable, for example, to dyspepsia or 
other functional derangements of the stomach. Physiological experiments 
have, as we have already observed, demonstrated that the cerebellum is the 
centre of equilibration, and that injury or irritation of this organ or of the 
parts immediately connected with it, such as the pons Varolii, corpora quad- 
rigemina, or crura cerebri, in the lower animals, is followed by vertiginous 
movements. It is probable, therefore, that in the human being vertigo is 
referable, in large proportion, to functional disturbances and organic lesions 
of the same parts. It is certain that affections of the cerebellum are 
generally, if not always, attended with failure of the power to maintain 
equilibrium. Affections of the eye and ear, and even of the spinal nerv- 
ous system, are also capable of causing vertiginous phenomena. In the 
case of the eye, vertigo depends, for the most part, on affections involving 
the muscles, such as loss of power in one or more of the recti of one eye, 
in consequence of which a convergent or divergent squint is produced; or 
on the presence of nystagmus. Vertigo referable to the ears is usually 
associated with deafness, and immediately due, according to Meniere's re- 
searches, to disease of the semicircular canals, injury to which has been 
shown by experiment on the lower animals to be followed, equally with 
injury to the crura cerebri, by vertiginous movements. In reference to 
affections involving the spinal nerves, it may be observed that the inco- 
ordinate movements of locomotor ataxy, and the oscillating movements of 
disseminated sclerosis and of paralysis agitans, are not unfrequently at- 
tended with the subjective phenomena of vertigo, especially if their influ- 
ence be not counteracted or neutralized by sight or hearing. Vertigo is 
frequently associated with headache, functional disturbance of the eyes 
and ears, sickness, and other phenomena. The recognition of the exact 
cause of vertigo in any case must be based less upon the simple vertiginous 
phenomena than on the accompanying symptoms. 



10. Impairment or Loss of Power of Speech. (Aphasia. Aphemia. 
v Amnesia.} 

We employ the above terms in their widest sense, and as including, 
therefore, not merely defects referable to, or manifesting themselves in, the 
organs of articulation, but defects relating to reading and writing. Para- 
lytic affections of articulate speech may be divided into four classes : first, 
that in which the motor nerves of the organs of speech are paralyzed in a 
greater or less degree, and where, therefore, the defect of speech is simply 
the result of inability to use these organs ; second, the class in which the 
co-ordinating centre of the movements of articulation is affected, and 
where the patient, having complete control over the movements of his lips 
and tongue for other purposes, is yet unable to utter articulate sounds ; 
third, the class in which the impairment of speech is central, where there 
is loss of memory of words, or amnesia, and other losses of mental attri- 
butes ; and, fourth, a complex class, including all those cases in which the 
conditions characteristic of the second and third classes are combined. 

a. The first class comprises a well-defined but rather wide range of 



852 



DISEASES OF THE NERVOUS SYSTEM. 



cases, among which may be enumerated those of right or left hemiplegia, 
general paralysis of the insane, general spinal paralysis, locomotor ataxy, 
disseminated sclerosis, chorea, glosso-laryngeal palsy, and lesion of one or 
more of the motor nerves of the organs of speech. In left hemiplegia and 
in paralysis of one portio dura or hypoglossal, the defect of speech is often 
scarcely appreciable, and rarely amounts to more than a little thickness of 
utterance. In general paralysis there is usually a little tremulousness of 
the tongue and lips when the attempt to speak is made, a little hesitation 
and thickness or inexactness of utterance, which become especially marked 
when the patient speaks with vehemence. In locomotor ataxy and dis- 
seminated sclerosis the defect of speech may present some degree of variety ; 
in some cases there is more or less slowness and tremulousness ; in others 
the slowness is attended with exaggerated efforts on the part of the lips 
and tongue to effect their purpose ; in others the syllables are unnaturally 
divided, and there is a tendency, as it were, to scan the sentences ; but in 
all, even though separate letters may be accurately enunciated, the more 
complex their combinations in w T ords the more clumsy and inexact does 
their pronunciation become, and the latter parts of long sentences, or of a 
sustained conversation, always contrast unfavorably in these respects with 
the beginning. In glosso-laryngeal paralysis, the early stages of defective 
articulation resemble those observed in general paralysis, but gradually 
the lips, tongue, and soft palate lose almost entirely their capacity for 
movement, and the patient loses not only the power of articulation, but 
that of retaining the saliva in his mouth, and that of swallowing. The 
character of the defective articulation of chorea need not now detain us. 

b. The second class of cases corresponds to the group to which Dr. 
Bastian endeavors to limit the use of the word aphemia, adopting the 
word from Broca, who, however, has employed it in a different and far 
wider sense. Typical cases of this kind are very rare. In them, patients 
recovering from an attack of unconsciousness are found to be entirely 
speechless, and to remain speechless for days, weeks, or even months, not- 
withstanding that they may have regained the use of every other faculty 
which might be supposed to have any, the remotest, connection with speech : 
that is to say, notwithstanding that they can hear, understand everything 
that is said to them, read, converse by means of writing, and use the lips 
and tongue with the utmost precision for every purpose excepting speech. 
Now in such cases as these it is obvious that the patient retains all his 
mental faculties, and that he thinks (as is probably usual) with the aid of 
words, which he still retains the power of expressing by means of writing; 
but which he cannot utter, not because he has lost the use of his muscles 
of articulation, but because the wish to speak does not evoke the combined 
automatic movements on which speech depends. In ordinary conversa- 
tion the words which express our thoughts flow automatically from our 
lips ; the complicated combinations of movements on which their utterance 
depends are executed momentarily and with the utmost precision, without 
any attention whatever being, as a rule, bestowed upon the movements 
themselves. 

Looking to the extreme complexity of these movements, it seems cer- 
tain that that part of the brain in which words are transformed into ideas, 
and are revived in thought, acts, in the process of transforming them again 
into articulate speech, upon the centres of origin of the various nerves of 
speech, through the intermediate agency of a special co-ordinating centre. 
This centre is probably situated somewhere in or below the corpus 



I 



APHASIA. 



853 



striatum ; and within it, on the receipt of the message from above, the 
various telegraphic communications with the nerve-origins below are 

I automatically so manipulated as to cause, through these latter, the organs 
of speech to execute the necessary combined movements. Words are 

j practically innumerable. The elementary articulate sounds, however, 
which by their combinations produce articulate language, are probably less 
than fifty in number, and this comparatively small number therefore also 

j represents all the groups of simultaneous combined movements which the 
tongue and lips can be called upon to execute. It seems probable, partly 
on these grounds, partly from the consideration that language (apart from 
the mere mechanism by which it is uttered) is a mental function, and 
partly from the consideration that the function of a co-ordinating motor 
centre is to regulate or combine groups of movements, that the duty of 
the assumed co-ordinating centre of speech must simply be to preside over 
that essential but comparatively subordinate department of speech which 
consists in the production of the elementary articulate sounds. If this 
view be correct, it is easy to understand how some lesion involving this 
centre or cutting off the direct communication either between it and the 
intellectual centre of language above, or between it and the nerve-nuclei 
below, might result in dumbness, while at the same time the command of 
language might in all other respects be retained perfectly, and the power 
of executing the most delicate movements with the lips and tongue remain 
intact. It is easy also to understand how, in such cases as this (consider- 
ing that all articulate sounds are merely the results of certain mechanical 
arrangements of the speech-organs) the patient who has lost the power of 
speech might be taught to copy these mechanical arrangements, and thus 
again to speak, exactly as deaf mutes are taught. The morbid anatomy 
of this class of cases has not been yet investigated. The patients in whom 
aphemia has been observed have had fits, epileptic or apoplectic, from 
which they have recovered with or without temporary paralysis. 

c. In the third class of cases there is amnesia, or loss of memory of 
words. In typical examples of this kind the patient, with perfect power 
of utterance, is yet incapable, from want of words, of joining in conversa- 
tion ; with perfect vision he is unable to read even to himself ; and with 
(it may be) entire command over his arm and hand, he cannot make him- 
self understood by writing, or even write. In most if not in all of these 
cases, however, there is not merely forgetfulness of words, but there is 
more or less inability to recall facts, to concentrate the thoughts, and to 
pursue any train of reasoning. An amnesic patient, when he attempts 
to speak, commences perhaps with one or two words correctly uttered, 
then hesitates for a word, probably uses a wrong one, notices that he is 
wrong, tries to correct himself, perhaps repeats the words that he first 
uttered, stumbles a little, and then, with a gesture of annoyance, comes to 
a stop. If his speech be carefully observed, it will generally be noticed 
that his vocabulary is limited to a very few words, and that he tends to 
repeat certain of these, and especially to repeat certain combinations of 
them ; and indeed he often appears to recall phrases more readily than 
single words. If asked to name even the most common things he fails in 
very large proportion, and fails probably to remember words which he has 
been taught to utter only a minute or two previously. Yet he seems to 
understand everything that is said to him ; he at once distinguishes the 
right name from the wrong when submitted to the test; and he can articu- 
late readily every word which is dictated to him. It is very interesting to 



I 



854 



DISEASES OF THE NERVOUS SYSTEM. 



note that uttered words entering by the ear are by a voluntary effort at 
once and perfectly reproduced by the organs of speech, and at the same 
time recall for the moment to his mind the ideas which properly attach to 
them. Such a patient may often be seen with a newspaper or book, over 
which he pores as if he derived the greatest interest from its perusal; but 
on asking him to read aloud he will probably indicate his inability to do 
so, and not even make the attempt ; or possibly he may pick out a word 
here and there which he recognizes, and which he pronounces with more 
or less approach to accuracy. It might be supposed that, although he 
cannot translate written into vocalized words, yet that written words con- 
vey to his mind through the eye their proper meaning, and that hence he 
really understands what he reads. This, however, is generally not the 
case, for if he be examined by leading questions he fails to show that he 
has any knowledge of what he seems to have been reading about. He 
will, however, not unfrequently point out here and there words, or even 
phrases, which he recognizes and perhaps utters. He seems, indeed, 
much in the condition of a child poring over the pages of a book written 
in a foreign language, which he has just begun to learn. If now asked to 
name letters he probably fails, just as he previously failed with words ; 
and, again, if asked to point out letters as they are named to him, his 
inability is equally marked. In fact, just as he has forgotten the names 
of things he has forgotten the names of letters, and consequently their 
value ; and he fails, partly on this account and partly from the complexity 
of the mental process which it involves, to attach any sound or any mean- 
ing to the various combinations of letters which stand for words. When 
he recognizes printed words, it is probably as a whole that he generally 
recognizes them : thus, he will sometimes point out his own name, though 
unable to point to, or designate, a single letter that it contains. 

A similar difficulty exists in regard to writing. If his hand and arm 
be not paralyzed, or only slightly thus affected, he can execute all accus- 
tomed delicate movements with them, and indeed can employ the hand as 
a mere machine just as well, probably, as ever he did. If he could draw, 1 
he can probably still draw, and he can copy the forms of geometrical 
figures, and therefore the forms of letters. He can write and print from a 1 
copy. If, however, he tries to write (and he is not unfrequently fond of 
writing) he either makes a series of unmeaning up and down strokes, 
manifesting even here a dim recollection of the art of writing, or he begins 
a word, perhaps his own name, correctly, and after writing a letter or two 
repeats them and then stops, or passes on into unmeaning strokes. If 
words are dictated to him he writes them even more incorrectly than those 
which he writes voluntarily, and probably writes letter-characters which 
are dictated to him as faultily as words. Yet not unfrequently, if he be [ 
set to copy from a printed page, he will translate the printed words (letter 
by letter) into their written equivalents as well and as quickly as if he were 
in perfect mental health, and this without being able to name or to under- 
stand the printed words and letters, or those which he himself forms. It is 
curious to observe here the correspondence that exists between the eye 
and the hand : the patient sees the printed word, and by an effort of the 
will reproduces it automatically in written characters, yet neither the word 
he sees, nor its written equivalent, nor the act of writing it, brings to his 
mind, even for an instant, any glimpse of its meaning. An amnesic pa- 
tient who is unable to write from dictation will often put down figures ! 
from dictation, and, further, perform simple arithmetical sums upon a slate 



APHASIA. 



855 



i with tolerable correctness. He may even perform sums in addition of 
money; and very curiously he will sometimes, while adding up, miscall 
the figures which he writes down correctly. 

Now the degree in which any one or all of the above peculiarities may 
be present in any case varies of course within very wide limits ; and so 
also does the degree in which the patient's memory of facts and power of 
concentrating his thoughts, and of reasoning, are retained. But the defi- 

j ciency of his mental powers is not to be measured by the degree of his loss of 

| memory of words. Many of those patients in whom the amnesic condition 
is extreme take such a lively interest in all that is going on around them, 

| play at simple games of skill so cleverly, are so quick in their movements 
and in the use of their .senses, and display such quickness of perception, 

| that they obviously possess considerable intelligence. We are apt indeed 
to give them credit for much more intelligence than they really possess. 

| It seems probable that, in proportion to their inability to recall facts and 
words by voluntary effort, they live more and more, as it were, in the 
objects which present themselves to their senses, and in the evanescent 
ideas which they evoke. 

But many amnesic patients present peculiarities which do not quite 
accord with the above description — these peculiarities being due either to 
the degree in which the patient is affected or to the fact that other forms 
of sensory, motor, or mental derangement are superadded. In some cases 
the aphasic condition is revealed only by the occasional misuse of certain 
words, or by the omission of certain words or letters in speaking or writing, 
or by the occasional employment of wrong endings or beginnings to words, 
or by the transposition of syllables or letters, or by the use for the word 
intended of some other word having a phonetical relation with it, or some 
analogy to it either in its meaning, its appearance, or the ideas it evokes ; 
in other cases the patient's vocabulary is limited to one or two sounds or 
words, such as ' yes ' or ' no,' or to a phrase or two, such as * damn it,' or 
6 can't afford it,' which he utters whenever he makes the attempt to speak, 
and sometimes without appearing to recognize that his language is in any 
degree peculiar. In other cases the patient does little more than repeat 
words which are dictated to him, and these he repeats over and over again 
until a newly dictated word displaces the former one from his memory. In 
other cases, again, he makes inarticulate sounds, which he utters volubly 
and with emphasis, and which, if carefully attended to, seem divided into 
lengths. These sounds, indeed, may have some obvious phonetic relation 
with words, and as the patient's condition improves become resolved into 
articulate speech. It may be added that amnesic patients not unfre- 
quently utter an unexpected oath or phrase under the influence of emotional 
excitement, just as paralyzed patients under similar circumstances are apt 
to move limbs over which they have no voluntary control ; and, further, 
that amnesic patients who have but few words at their command, when 
asked to repeat from dictation things that they have learned, such as 'the 
Lord's Prayer,' the numerals, or the alphabet, will often, instead of repeat- 
ing the word or sentence actually dictated, utter the word or sentence 
which immediately follows, and possibly continue their recitation until 
they become confused and mumble unintelligibly, or repeat themselves. 
It is this third group of cases, together with the fourth group (to be con- 
sidered presently) to which the investigations of M. Broca and others 
chiefly relate. It is in these cases that there is almost invariably right 
hemiplegia dependent on some lesion of the left cerebral hemisphere, 



856 



DISEASES OF THE NERVOUS SYSTEM. 



occupying, roughly speaking, the district which the left middle cerebral 
artery supplies, namely, the corpus striatum and the wedge of nervous 
substance extending outwards, towards and including in its base the island 
of Reil with some of the neighboring convolutions — more precisely (ac- 
cording to M. Broca) the posterior third of the third frontal convolution. 
It is this district in which the effects of cerebral embolism are most 
frequent. 

d. The fourth group of cases includes all those in which amnesia is as- 
sociated with aphemia, or with both aphemia and paralysis of the organs 
of speech. These cases are very numerous, and present great varieties of 
symptoms, according to the degree in which each of the above-mentioned 
conditions is present, absolutely or relatively. In typical cases of this class 
the patient, after an attack of right hemiplegia, loses absolutely the power 
of speech, or at most utters some one or two inarticulate sounds, and per- 
haps has some difficulty in using the tongue and lips ; but he apparently 
understands everything that is said to him, and when asked to point out 
words and letters on a printed page, probably points them out correctly. 
So far the symptoms are those of aphemia. But presently the patient 
gradually or suddenly recovers the power of articulate utterance, and it is 
then found that he is suffering from amnesia in addition to aphemia, that 
he has in a greater or less degree forgotten the names of things, perhaps 
his own name. 

In conclusion it may be suggested that it seems convenient still to em- 
ploy the word 'aphasia' in that general sense in which it has been used by 
Trousseau, as inclusive of all difficulties of speech which come under the 
second, third, or fourth of the above groups ; and that, inasmuch as the 
aphasic condition thus defined includes two perfectly distinct clinical phe- 
nomena, which, though often combined, may exist separately, it seems also 
convenient to have a distinct name indicative of each of them, and appli- 
cable to those cases in which one or other of them occurs separately. The 
terms 'aphemia' and 'amnesia' may be thus employed. 

We may here call attention to the facts : that articulation and phonation 
are distinct elements in spoken language ; that phonation in some degree 
survives in all cases of aphasia, and that not unfrequently aphasic patients 
who can utter only one or two words can yet hum tunes with facility ; and 
that loss or impairment of phonation is usually the result of disease in- 
volving directly the nerves of the intrinsic muscles of the larynx;, or of 
hysterical and other such functional disturbances. 

11. Mental and Emotional Disturbances. 

It may be pointed out in conclusion that all forms of mental disorders 
are apt to attend not only brain diseases, but a large number of affections in 
which the brain is only secondarily or remotely implicated. This subject 
is much too vast to admit of separate discussion here. It may, however, 
be observed that patients may suffer in feeling, intelligence, and will, either 
conjointly or separately, and that these may be exalted, perverted, or im- 
paired. Thus, as regards feeling, he may be excited (angry, boisterous, 
merry), depressed (melancholy, anxious, fearful), or suspicious, mischiev- 
ous, or sullen ; as regards intelligence, his ideas may flow rapidly and with 
vivacity, he may have delusions, his reasoning powers may be perverted 
or impaired, his memory may fail, or there may be incoherence or general 
mental .imbecility ; and, as regards will, he may show abnormal obstinacy 

\ 



ELECTRICITY IN NERVOUS DISEASES. 



857 



or tenacity of purpose, extreme vacillation, or listlessncss and apathy, or 
incapacity for exertion. The various forms of delirium, the low mutter- 
ing, the busy or garrulous, and the maniacal — are all common in different 
forms of disease. Insanity in all its varieties is apt to attend or supervene 
upon a large number of acute or chronic disorders, whether these affect 
the brain or other parts. And, lastly, coma — the abeyance of all mental 
phenomena, the condition in which the patient lies as in a profound sleep 
and insensible to every external influence — if not the primary disorder, 
constitutes the common fatal termination of most of the other mental 
affections which have been enumerated. 

C. Electricity in Nervous Diseases. 

The employment of electricity is so important not only in the treatment 
of nervous diseases but for the purposes of diagnosis, that a few remarks 
in reference to its mode of application and uses will not be out of place. 

Two forms of electricity are employed in medicine ; one the continuous 
or galvanic current, the other the induced or far adic current. The former 
is the kind of electricity which is developed by chemical decomposition, 
and is usually obtained from one or more similar cells, arranged in a series 
or circuit. For medical purposes a battery of from twenty to fifty cells is 
usually employed. The latter is the kind of electricity furnished by mag- 
neto-electric and other induction machines. The galvanic current is char- 
acterized : first, by constantly flowing in one direction, namely, from the 
positive pole or rheophore to the negative pole ; second by its compara- 
tively low intensity, and considerable quantity — its intensity, however, 
depending on the number of cells employed, its quantity on the size of the 
elements ; third, by its possession of powerful chemical and thermal pro- 
perties which are specially observable at the point of application of the 
negative rheophore; and fourth, by its comparatively little influence in 
causing muscular contraction. The faradic current is of instantaneous 
duration, occurs only at the moment of making or breaking contact, and 
takes place alternately in both directions. It is remarkable for its high 
intensity, and for the powerful effect it has in causing contraction of mus- 
cles, and in acting on motor and sensory nerves. But it has no thermal 
or chemical influence whatever. 

The rheophores, or instruments by means of which electricity is applied, 
are of various kinds ; but they should always be furnished with insulating 
handles, so that they may be freely and safely manipulated by the operator. 
The larger ones generally consist of a sponge fixed in a metallic cup ; the 
smaller ones are usually an ovoid metallic knob covered with wash-leather. 

If the electricity is to be limited in its action to the skin the rheophores 
must be used dry, and it is well even to dust the skin with a little dry 
powder ; but if, as is usually the case, muscles or nerves are to be acted 
on, they should be well moistened with hot salt and water, as also should 
the surfaces to which they are applied. 

There are three different ways in which galvanism or faradism may be 
used to influence muscles. First, superficial muscles may be acted upon 
individually by placing the rheophores immediately over the belly of each 
muscle which it is desired to affect. In this case the rheophores should 
always be situated within a short distance of one another. Second, one 
rheophore may be applied over the trunk-nerve leading to a group of mus- 
cles, and the other successively over the different muscles supplied by this 



858 



DISEASES OF THE NERVOUS SYSTEM. 



nerve, each of which will thus in turn be caused to contract. Third, one 
rheophore may be fixed on some indifferent part of the surface, as for ex- 
ample on the nape of the neck, while the other is placed over the nerve 
leading to the individual muscle or group of muscles which it is intended 
to influence. By this method, which is sometimes termed the indirect 
method, many deep muscles which could not otherwise be reached may 
readily be made to contract. It need scarcely be said that the successful 
employment of this method requires accurate knowledge of the situations 
at which muscular nerves are most accessible. In this case the first rheo- 
phore should be of large size, but the second or that to be applied to the 
nerves should be small and ovoid. 

The same methods of procedure may be employed for galvanizing or 
faradizing nerves. 

In employing electricity for diagnostic purposes it is important: first, 
that if possible corresponding healthy and diseased parts in the same indi- 
vidual should be compared; second, that the patient should be as far as 
practicable at absolute rest, and especially that the parts to be examined 
should be placed under exactly similar conditions ; third, that the rheo- 
phores should be the same and at equal distances apart, and the strength 
of the current identical, in each parallel series of observations; and fourth, 
that as a general rule, in testing the diseased side, the feeblest current 
capable of affecting the healthy side should be employed. 

Faradism has, as has been pointed out, a very powerful influence in 
causing contraction of healthy muscles. Galvanism in the same case causes 
contraction only at the moment of breaking circuit. Its peculiar proper- 
ties are best manifested when the interruptions are slow. The effects of 
electricity on paralyzed muscles are variable. In hemiplegia there is no 
necessary change in this respect ; but in the early period, and at times 
when inflammation or other irritation is present, there is often some in- 
crease of reaction to both forms of stimulus ; while later, sometimes from 
mere disuse, sometimes in connection with secondary degenerative nervous 
lesions, this undergoes diminution. In paraplegia the electrical phenom- 
ena are much the same and obey the same rules, but here both faradic and 
galvanic irritability are in the early stage of the disease more commonly 
and more markedly increased than in hemiplegia. In destructive lesions 
of motor nerves or of their nuclei of origin the consequences which ensue 
are remarkable and for the most part distinctive. At first the reactions of 
the paralyzed muscles both to faradism and to galvanism are normal. Then 
both varieties of irritability may undergo some degree of diminution. At 
the end, however, of a week or from this to the fourteenth day, faradic 
contractility diminishes considerably, and in the course of a few weeks 
probably becomes wholly lost. But while faradic contractility is disap- 
pearing, galvanic contractility increases, and in the course of a short time 
the affected muscles probably react to a current half as strong as that which 
is required for producing the same effect on the healthy muscles. At a 
late period the response of the diseased muscles to galvanism in its turn 
diminishes and disappears. 

As regards nerves it appears that for a few days after their division 
there is a slow increase of both galvanic and faradic irritability. But soon 
gradual decrease takes place ; and finally all irritability ceases to both 
forms of electricity. The electric irritability of nerves once lost is very 
slow to return, and it is an interesting fact that the recovering nerve some- 
times allows the passage of the mental stimulus while it is still wholly 



ELECTRICITY IN NERVOUS DISEASES. 



859 



irresponsive to electricity. It is suggested by Erb that this phenomenon 
is dependent on thickening of the neurilemma. Onimus considers that 
the failure of paralyzed muscles to respond to faradism while they still react 
to galvanism is due to changes having recurred in the intra-muscular 
nerves. It need scarcely be added that when motor nerves have lost 
their electric irritability, it is impossible to stimulate muscles by the indi- 
rect method. 

Electric sensibility may be diminished or increased. In general, dimi- 
nution attends ordinary anaesthesia, and increase accompanies hyperesthe- 
sia. But it may be observed that variations of muscular and cutaneous 
sensibility are not always in relation with one another. Muscular sensi- 
bility is usually impaired when electric contractility is diminished, and 
augmented when the latter is excessive. Muscular sensibility is increased 
in cases of muscular rheumatism, and often diminished in hysterical 
paralysis even when the muscles contract strongly under the electric 
stimulus. 

It may be added that the condition of things in hysteria presents much 
variety. But in hysterical paralysis, especially when the muscles have 
wasted, there is often considerable, but equal, loss of faradic and galvanic 
irritability. This is frequently associated with diminution of cutaneous 
electric sensibility. 

Therapeutical uses of electricity. — For a full consideration of this im- 
portant subject we must refer the reader to special treatises. 1 

Meanwhile, however, we may direct attention to a few points in regard 
to it. Besides its caustic and cauterizing effects (for which galvanism is 
of special use to the surgeon, and as a counter-irritant), electricity pos- 
sesses stimulant and sedative properties which are of great therapeutic 
value. Its stimulant properties are specially serviceable in the treatment 
of paralytic conditions ; its sedative and anodyne properties are useful in 
assuaging various forms of spasms, but are chiefly valuable in the relief or 
cure of neuralgic affections. 

Faradism is in general the more powerful stimulant of muscular and 
nervous tissues; and it is usually applicable to all paralytic or paretic cases 
in which any trace of. faradic irritability remains, whether it be used for 
restoring parts which have lost their powers, or for preventing the wasting 
of disused or disabled muscles. The slowly interrupted galvanic current 
is also a stimulant, but in most cases a less powerful stimulant than the 
other. It possesses, however, in addition to the power of exciting muscu- 
lar contractions, a special influence over the nutrition of the parts to which 
it is applied. It is better adapted than faradism for the treatment of 
muscles which have lost their faradic contractility, and it is often em- 
ployed by preference in the treatment of those which, in addition to being 
paralyzed, are wasted. Faradism and galvanism are alike useless in para- 
lyzed muscles which retain, or have reacquired, their normal electrical 
reactions. 

For sedative purposes faradism is sometimes employed. But it only 
diminishes spasm or contractility by causing fatigue, and therefore, gene- 
rally, is not best suited for this purpose. The most valuable sedative for 
muscular spasm is the continuous galvanic current. This is the only form 
of galvanism that should be used in the treatment of pain. It is usually 
advisable to include the painful region between the rheophores in this case, 



1 See especially Dr. Poore's ' Text Book of Electricity.' 



860 



DISEASES OF THE NERVOUS SYSTEM. 



and in neuralgia to apply the one pole over the spinal column above the 
point of origin of the affected nerve, and the other in turn to the several 
painful spots. 

In the habitual use of faradism or galvanism for the above purposes, it 
is important: in the first place, to employ no greater strength of current 
than is absolutely necessary to effect the intended result — if to cause mus- 
cular contraction, the weakest current capable of causing contraction, if to 
relieve pain or spasm only such a current as produces a slight degree of 
tingling; in the second place, that each sitting should not, as a rule, be 
continued beyond five, ten, or at most, fifteen minutes; and in the third 
place, that during this period, every affected muscle or painful point should 
be brought successively under treatment, and that, in the case of the gal- 
vanic current, the negative pole should never be kept for any length of time 
on oue spot. 



II. INFLAMMATION OF THE CEREBRAL AND SPINAL 
DURA MATER. PACHYMENINGITIS. 

Causation Inflammation of the dura mater is either traumatic, or the 

consequence of the extension of disease from parts external to it, or it is 
of idiopathic origin. With traumatic inflammation the physician has little 
to do. Inflammation from extension may be secondary to erysipelas or 
other such affections of the surface of the head, but is mostly traceable to 
caries of the petrous or mastoid portion of the temporal bone, or to similar 
disease of the frontal plate of the ethmoid or adjoining parts of the sphe- 
noid or orbital parietes, or to syphilitic or other like affections of the bones 
of the skull, or to caries of the vertebrae, or to sacral bed-sores. 

Morbid anatomy. 1. Cerebral dura mater When inflammation ex- 
tends from the bones of the skull to the dura mater this membrane becomes 
thickened and softened, and its connection with the subjacent bone more 
or less loosened. Not unfrequently a false membrane forms upon its free 
aspect, and may cause it to adhere to the corresponding surface of the brain ; 
or suppuration takes place which may either be limited by adhesions, or 
become widely diffused in the cavity of the arachnoid. Further, inflam- 
matory overgrowth or actual suppuration often takes place between the 
skull and the dura mater, and in the latter case the dura mater is apt to get 
perforated, and the pus to be discharged into the cavity of the arachnoid. 
When inflammation occurs in the neighborhood of the sinuses, these are 
liable to get involved and to become the seat of thrombosis or suppuration, 
or the source of pyaemia. This event is especially common when the 
meningitis is due to disease of the temporal bone, in which case the lateral, 
petrosal, and cavernous sinuses may either or all of them suffer. 

2. Theca vertebralis. — The inflammatory products which are developed 
during the progress of vertebral caries tend sooner or later to accumulate 
in the neighboring part of the spinal canal, between the bones and dura 
mater. In the majority of cases, according to M. Michaud, this accumu- 
lation takes place in the first instance between the back of the bodies of 
the vertebras and the vertebral ligament, which gradually undergoes erosion 
and perforation. The theca vertebralis then becomes involved in the in- 
flammatory process, the outer surface of its anterior portion undergoing 
proliferation, and possibly forming a kind of caseous button, which, when 



INFLAMMATION OF THE DURA MATER. 



861 



the cord becomes compressed in this disease, constitutes for the most part 
the agent of compression. Inflammation of the dura mater, secondary to 

! vertebral disease, may occur in any part of its length. In patients who 
are suffering from extensive bed-sores of the sacral region, it frequently 

! happens that the sacral and coccygeal bones become exposed and eroded. 
In some of these cases the sacro-coccygeal ligaments get destroyed, and 
hence the inflammatory process extends into the vertebral canal, or, in 

j consequence of perforation of the theca vertebralis, into the cavity of the 

I arachnoid. Occasionally, consecutively either to vertebral disease, or to 
the condition last mentioned, or from some idiopathic cause, the theca 

j vertebralis becomes inflamed throughout, or in great part of its extent, and 
suppuration takes place on either side of it. The pus which forms ex- 

! ternally first accumulates in the spinal canal, and then (if the case be of 
sufficiently long duration) escapes with the nerves through the intervertebral 

| foramina, and follows their primary ramifications : forming it may be a 

| longitudinal series of abscesses behind on either side of the vertebral spines, 
and a similar series in front on either side of the bodies of the vertebrae, 
of which those in the abdomen possibly constitute multilocular psoas ab- 

i scesses. The pus which is effused from its inner aspect distends the cavity 
of the spinal arachnoid, and may spread thence to the base of the brain. 

Whenever the pus which is diffused throughout the arachnoidean cavity 
is derived from gangrenous sources, or from* areae of disease communicating 
with the external atmosphere, it is fetid, greenish in hue, and dirty-looking, 
and on post mortem examination the surface of the brain or cord in rela- 
tion with it is generally found stained to a greater or less depth by imbi- 
bition. This peculiarity is most frequently observed in meningitis due to 

! perforation of the theca vertebralis by bed-sores, and in that which takes 
place consecutively to chronic ear- disease, and is occasionally met with in 
other varieties of caries of the skull or vertebra?. 

3. Pachymeningitis is the name given to a peculiar form of chronic in- 
flammation of the dura mater. This may be the conseqence, as are the 
varieties of meningitis just discussed, of injury or of subjacent disease. 
But it is more commonly of spontaneous orgin. In the head it commences, 
for the most part in the area of distribution of the middle meningeal artery, 
with the formation over a greater or less extent of surface of a delicate 
adherent film, which consists partly of embryonic corpuscles, but mainly 
of large irregular thin-walled capillaries. Other similar films become de- 
veloped in slow succession one upon the other over the diseased area, until 
the adventitious formation attains considerable thickness : the deeper- 
seated laminae meanwhile becoming denser, more fibrous, and less vascular. 
Owing to the large size and extreme delicacy of the newly-formed blood- 
vessels, rupture, with extravasation of blood, is of frequent occurrence. 
For the most part the hemorrhages are minute and numerous, and result 
in the precipitation of crystalline and other forms of blood-pigment ; not 

' unfrequently, however, they are abundant, and form large accumulations 

j between the laminae, giving, it may be, to the whole growth the aspect of 
a mere clot. Pachymeningitis of the theca vertebralis usually takes place 
in the neighborhood of the cervical enlargement of the cord. The dura 
mater becomes greatly thickened by the formation of a series of concentric 
fibroid laminae, successively developed upon its inner aspect. All of them, 
even the most recent, are dense and tough, and little vascular or inclined 

| to bleed, and thus differ from those occurring in the cerebral dura mater. 
In the progress of the disease the pia mater is apt to become involved, and 



I 



862 



DISEASES OF THE NERVOUS SYSTEM. 



sooner or later the cord gets compressed, and the nerves in their passage 
to the intervertebral foramina also implicated. 

Symptoms and progress — The symptoms which attend inflammation of 
the dura mater are necessarily vague, unless the inflammation be suppura- 
tive, or have extended to the pia mater, bloodvessels, or subjacent nervous 
matter, or involve the compression of the nervous centres, or of nerves. 
They are especially vague, if not trivial and misleading, in the earlier 
stages of the chronic forms of the disease. If suppuration take place, 
febrile disturbance with rigors is likely to ensue ; and, as has often been 
observed, the fever is then apt to assume an irregularly remittent or even 
intermittent type, and thus the patient's illness may for a time have no 
little resemblance to an attack of ague. If the disease go on to the effu- 
sion of inflammatory products into the cavity of the arachnoid, or to the 
involvement of the pia mater or substance of the brain or cord, or of nerves, 
special symptoms referable to these several parts will of course be devel- 
oped. We proceed to consider in detail the symptoms of the different 
varieties of inflammation of the dura mater, the morbid anatomy of which 
we have already passed in review. 

1. Acute inflammation of the cerebral dura, mater, as met with in medi- 
cal practice, is almost always due to chronic disease of the ear. Recent 
otitis, however intense, is rarely followed by it. The patient, who may be 
of any age between early childhood and advanced senility, has suffered 
probably for years, perhaps nearly all his lifetime, from deafness, attended 
with more or less constant, more or less copious, and more or less offensive 
aural discharge, and occasional attacks of earache. 

The supervention or' meningeal mischief is induced sometimes by ex- 
posure to cold, sometimes by a blow on the affected side of the head or on 
the jaw, and not unfrequently seems to occur spontaneously. Very often 
it is preceded by or attended with sudden diminution or cessation of dis- 
charge. The patient is usually attacked with intense pain in the affected 
ear or its neighborhood, or possibly with severe headache referable to some 
other part of the head. This, which is generally more or less constant, is 
attended with exacerbations which are often so violent that he writhes and 
groans or grinds his teeth and even shrieks out. Not unfrequently it con- 
tinues as long as the patient retains consciousness ; but it often remits or 
disappears, and in some cases is wholly wanting from first to last. It is 
probably for the most part referable to the disease of the ear rather than 
to that of the internal parts. Sometimes a paroxysm of convulsions is the 
earliest specific indication of meningeal mischief : sometimes vomiting ; 
sometimes an attack of vertigo, incoherence, or rambling ; sometimes a 
rigor. The disease is subject to remarkable variations both as to duration 
and as to the phenomena which attend it. Assuming it to prove fatal, the 
patient may die in the course of two or three days; more commonly he 
survives for two or three weeks ; but his life may be prolonged for several 
months. In the last case especially intervals of apparent restoration to 
health probably occur ; thus, in some instances, the patient has a convul- 
sive attack, attended perhaps with vomiting, from which he recovers, and 
a second attack which proves the precursor of fatal symptoms does not 
take place for some days or weeks ; in some instances he has strabismus 
and double vision, which may disappear from time to time, but are finally 
associated with graver phenomena; in some he suffers from a combination 
of symptoms threatening speedy dissolution, from which, nevertheless, he 
emerges, but only to become sooner or later the victim of relapse. 



INFLAMMATION OF THE DURA MATER. 



863 



The symptoms of the established disease comprise, in addition to head- 
ache localized in the ear or occupying the forehead, vertex, occiput or 
I other parts of the head, vertigo, intolerance of light and sound, hyperes- 
thesia, neuralgic pains in the head, neck, and limbs, nausea and vomiting, 
j sleeplessness, restlessness and irritability, muttering, busy or maniacal de- 
lirium, convulsions, local or general, occurring at rare intervals or following 
one another in rapid succession, paralysis limited to certain of the cerebral 
I nerves or hemiplegic, drowsiness and coma, together with febrile symp- 
toms. But these are not all necessarily present in the same case. Occa- 
sionally the patient, after suffering from severe pain in the ear, and possibly 
indefinite symptoms of brain-affection, falls into a state of collapse ; some- 
times he suffers mainly from convulsions, which are attended or succeeded 
by paralysis and coma; sometimes paralytic symptoms are the main feature 
of his malady — he becomes hemiplegic or has paralysis of some of the 
| muscles of one of the eyeballs or of the portio dura, or he has difficulty in 
speech or deglutition, or he loses the sight of one or both eyes ; some- 
times he suffers mainly from mental derangement ; sometimes he has fre- 
quent and severe rigors, coming on at more or less regular intervals, with 
j other febrile symptoms, such as coated tongue, heat and dryness of skin 
alternating with perspirations, rapid pulse, and the like. In other cases 
the skin is cool, the pulse of normal rate, and there is total absence of 
febrile reaction. 

The differences of symptoms which different cases present are no doubt 
in great measure attributable to differences in respect of the depth or super- 
ficial extent to which the inflammatory process extends within the skull. 
If the inflammation be limited to the dura mater, even should this become 

! sloughy and pus accumulate between it and the bone, the symptoms are in 
a large number of cases distinguishable from those due to otitis alone, and 
may be uncomplicated with fever. Again, if the inflammation reach the 
free surface of the dura mater, and especially if pus escape into the arach- 
noidean cavity, it is natural that aggravated brain-symptoms should be 
suddenly excited, that more or less fever should be developed, that some 
of the nerves at the base of the brain should become implicated, and that 
some of the symptoms of cerebro-spinal meningitis, such as retraction of 
the head and pain on moving it, should be experienced. Further, if 
abscesses form in the contiguous brain-substance, symptoms due to their 
presence are likely to arise. When inflammation of the dura mater in- 
volves thrombosis of the sinuses which are contained in its laminse, escape 
of blood from contiguous parts of the brain may be impeded. The most 
interesting phenomena, however, are those which are referable to the veins 

j of the face and neck which are in continuity with the obstructed sinuses. 
Thus it sometimes happens that the veins in the eyelids and conjunctiva 

j of the affected side get preternaturally distended with blood ; or that in- 
flammation of the internal jugular in the neck occurs, with formation of 

i deep-seated abscesses in that situation. Optic neuritis, too, is often present. 

| Lastly, pyaemia is not unfrequent ; and, although rigors may be caused by 
local suppuration or by effusion of pus into the arachnoid, they are often 

j an indication that the affection of the ear has become complicated with 

i purulent affection. 

It may be added : that the pulse is liable to great variations, that it 

j may be accelerated, or of normal rate throughout, that it is sometimes 
preternaturally slow, and generally, when death approaches, becomes very 
rapid and feeble ; that the skin is sometimes hot and dry, but often per- 



864 



DISEASES OF THE NERVOUS SYSTEM. 



spires profusely, especially towards the close, and that generally during 
the course of the disease Trousseau's 'tache eerebrale' can be elicited; 
that the tongue differs in its character, is often natural, but tends to be- 
come coated, and with the approach of death dry and brown ; that the 
evacuation of urine and feces is often performed unconsciously ; and that in 
the course of the disease symptoms are sometimes relieved by the sudden 
discharge of pus from the ear or even from the nose. 

Death is usually due to collapse or to coma ; it may, however, be caused 
by asphyxia, or be traceable to the effects of pyaemia. 

2. Pachymeningitis of the cerebral dura mater — The symptoms which 
attend this disease are exceedingly vague, and none the less so that it usu- 
ally affects aged persons in a state of imbecility or dementia. It has also 
been observed, according to M. Lancereaux, in cases of chronic alcoholism 
and chronic pulmonary phthisis. The symptoms include pain in the head, 
vertigo, failure of the mental powers, and gradually increasing hemiplegia, 
Avith occasional epileptiform or apoplectic attacks, in one of which the pa- 
tient probably dies. 

3. Acute general inflammation of the theca vertebralis, such as results 
from its perforation by a bed-sore, or the extension of inflammation occa- 
sionally following fracture or caries of the spine, is sometimes attended 
with marked symptoms, but is often extremely obscure in its indications. 
The symptoms which may be looked for are : pain in the course of the 
spine, sometimes of an exceedingly intense character, and, for the most, 
part, liable to aggravation by any movement, voluntary or involuntary, of 
the limbs or of the trunk or of the head and neck ; more or less rigidity 
of the muscles, with perhaps twitching; and, at the same time, more or 
less loss of motor power, and probably cf sensation, and of control over 
the bladder and rectum. To these, cerebral symptoms are apt to be super- 
added, more especially delirium, convulsions, and coma. Further, there 
may be tenderness in the course of the spine, due partly to the disease 
within it, partly, perchance, to the extension of suppuration into the 
muscles of the back. In cases of sufficiently long duration, and sufficient 
intensity, it is possible that psoas abscesses may be discernible by palpa- 
tion in the neighborhood of Poupart's ligament. When the inflamma- 
tion is due to the extension of bed-sores which have become developed 
during the progress of paralytic or other diseases, attended with impair- 
ment of the mental faculties, its presence is almost certain to be over- 
looked. Some degree of febrile disturbance will probably always be 
present. 

4. Caries of the vertebrce, even when it is attended with considerable 
displacement, does not, of itself, usually cause paralysis. The paraplegia, 
indeed, which so commonly attends the disease, is almost invariably due 
to the extension of the inflammatory process to the membranes of the cord 
and to the cord itself, and to pressure caused by the accumulation of inflam- 
matory products. 

Among the early symptoms of involvement of the nervous contents of 
the spinal canal (in addition to local pain and tenderness, and possibly 
angular curvature, indicative of the bone affection) must especially be 
noticed burning pains in the course of some of the nerves springing from 
the implicated portion of the cord. These pains, according to the situa- 
tion of the disease, may involve the nerves of one or both shoulders or arms, 
or one or both great sciatic nerves, or certain of the intercostal nerves, or 
of those of the abdominal walls. They are liable to come and go, and 



INFLAMMATION OF THE DURA MATER. 



865 



when continuous are often attended with exacerbations ; moreover, there 
may be more or less hyperesthesia in the area of their distribution. The 
sense of constriction, often likened to the feeling as of a cord drawn tightly 
round the chest or abdomen, which is so commonly complained of by para- 
plegic patients, belongs to the same category. These morbid sensory phe- 
nomena are due to involvement of the sensory roots of spinal nerves, which 
generally occurs before the cord itself suffers; and it not uncommonly 
happens at this period that erythematous or vesicular eruptions or pem- 
phigus becomes developed in the area of distribution of the affected nerves 
or even more extensively. It need scarcely be said that motor branches 
may also be involved, and that limited motor paralysis and atrophy of 
muscles may ensue. If the disease occupy some considerable length of 
the spinal canal, or a part in which nerves only are present, the several 
phenomena due to implication of nerves alone may become pretty widely 
distributed. Thus, if (as not unfrequently happens) the disease occupy the 
situation of the cervical enlargement, there may be hyperesthesia, burn- 
ing pains, and cutaneous eruptions, involving one or both arms, with flac- 
cidity and wasting of the muscles, and rapid loss of faradic contractility, 
followed, after a time, by anesthesia and complete motor paralysis of the 
same parts, but without any involvement whatever of the lower part of the 
| body ; if it be in the situation of the Cauda equina, one or both lower ex- 
tremities will probably suffer in the same manner as the arms in the former 
case. In either case, there will be partial or total absence of reflex move- 
ments in the affected limbs. 

After a time, which varies in different cases, symptoms due to involve- 
ment of the cord come on. These consist, in the first instance, in numb- 
I ness, tingling, or formication in the affected limbs, together with some 
impairment of muscular power. The latter generally increases more or less 
i rapidly until complete motor paralysis is established. The impairment of 
sensation, on the other hand, for the most part remains stationary, or under- 
goes amendment, or varies from time to time. But it may, of course, go 
on to absolute anesthesia. As a rule, the muscles below the seat of dis- 
ease, even if there be total abolition of sensation and motion, retain their 
natural tonicity and plumpness ; their faradic contractility remains normal 
or increases ; and reflex movements may be much more readily induced in 
them than in health. Such movements, indeed, are often provoked by the 
contact of the bedclothes, or the passage of evacuations. Occasionally, 
however, there is marked diminution or even abolition both of reflex ac- 
tion and of faradic contractility. If the involvement. of the cord persist, 
the ordinary ascending and descending lesions take place, the former along 
the posterior median columns, the latter along the lateral columns. The 
progress of these complications is attended with : aggravation of reflex 
phenomena, and especially the occasional occurrence of tremulous move- 
ments, lasting for a few seconds or even for many minutes at a time, in 
the affected limbs; the supervention from time to time of clonic or tonic 
spasms ; and gradually increasing rigidity of the muscles, which, in the 
i first instance goes along with extension of the limbs, but at a later period 
| with flexion. 

The symptoms which attend the form of paraplegia under consideration 
I present considerable differences, in dependence partly upon the situation 
| of the spinal caries, partly upon the degree in which the cord is involved. 

Thus, when the disease is in the dorsal or lumbar region, one lower ex- 
I tremity only may be involved, or both may suffer in different degrees, or 
55 



866 



DISEASES OF THE NERVOUS SYSTEM. 



there may be cross paralysis, with loss of motion on one side and impair- 
ment of sensation on the other ; when the disease is in the neck the arms 
are commonly affected prior to the legs, and they may be involved un- 
equally ; and, even when legs and arms are all implicated, the paralytic 
phenomena in each may present differences both in degree and in kind. 
Thus, also, while the rectum and bladder are often little if at all compro- 
mised when the lumbar or lower dorsal region is affected, want of control 
over these viscera is usual when the disease involves the upper dorsal or 
cervical region ; and, indeed, in the latter case this want of control occa- 
sionally precedes all other paralytic symptoms. Further, when the cervi- 
cal spine is the seat of disease, various phenomena, of more or less interest 
or importance, are apt to be superadded to the simple paraplegic symptoms, 
among which may be enumerated affection of the pupils of one or both 
eyes — in the first instance dilatation, at a later period, and more commonly, 
contraction ; cough, difficulty of breathing and of speech ; difficulty of 
deglutition, hiccough, vomiting and gastralgia ; epileptic attacks; and , 
permanent slowness of the pulse, with frequent tendency to faint. 

The prognosis of paraplegia dependent on caries of the vertebrae is, so 
far as the paralysis is concerned, not unfavorable : that is to say, presum- 
ing that the patient is not carried off by the effects of long-continued sup- 
puration or of degenerative changes in internal organs, by rapid extension 
of inflammation throughout the cord, or by pulmonary phthisis or other 
complications, there is always good reason for anticipating, in a case that 
comes early under observation, a more or less complete restoration of 
motion and of sensation. Cures have often been effected in patients who 
had been completely paralyzed for one or two years, or even longer. And, 
indeed, it has been shown by anatomical evidence that substantial recovery 
.has occurred in cases in which the cord has been permanently reduced in 
diameter- by pressure, and impaired in its texture by interstitial growth, or 
the development of secondary ascending and descending lesions. It is 
obvious that those patients who have caries of the cervical vertebrae incur 
many more,, and more serious, risks than those who suffer from dorsal 
caries ; and it may be added that when the atlanto-axial articulation is the i 
seat of disease sudden death from rupture of the ligament and consequent 
sudden compression of the upper extremity of the cord is to be dreaded. 
Apart from the causes of death which have already been enumerated, para- 
plegic patients are apt to sink from the effects of bed-sores, or from the I 
consequences of vesical and renal inflammation. 

5. The symptoms referable to cervical pachymeningitis are not unlike 
those which sometimes attend cervical caries. The affection presents two 
stages. The first, or painful stage, which lasts two or three months, is 
characterized by extremely acute pains in the back of the neck, shooting 
thence to the head and along the upper extremities. These are for the 
most part constant, but liable to exacerbations. The pains are attended 
with rigidity of the muscles, most strikingly manifested in those of the 
neck, which is kept fixed in a position identical with that which is assumed 
in cervical caries. At the same time the patient complains of formication, 
a sense of w r eight in the limbs, and more or less loss of muscular power. 
Bullous eruptions, too, are not unfrequent. The above phenomena are due 
to compression and irritation of the nerves. In the second stage the nerves 
become more or less disorganized, and the spinal cord suffers. The pains 
in the arms now cease but the muscles become paralyzed and undergo 
atrophy. It is remarkable, however, that the muscles of the forearm sup- 



INFLAMMATION OF THE DURA MATER. 



867 



plied by the musculo-spiral and median nerves are mainly implicated, 
especially those supplied by the median. Consequently the extensors pre- 
dominate over the flexors, and the hand assumes the form of a claw. This 
peculiarity, though not special to cervical pachymeningitis, is special to it 
among diseases of spinal origin causing muscular atrophy. Subsequently 
contractions of the affected limbs take place, and arese of total anaesthesia 
appear in them and on the upper part of the trunk. Later the lower ex- 
tremities become paralyzed and contracted, but do not undergo atrophy. 

Treatment The treatment of inflammatory affections of the dura mater 

and of the lesions so commonly associated with them is on the whole un- 
satisfactory. We have, as a rule, little or no direct influence over the 
progress of acute internal inflammation ; and chronic inflammatory pro- 
cesses occurring in deep-seated parts are equally seldom amenable to direct 
treatment unless they be due to certain specific diseases. 

1. If we have reason to suspect the presence of circumscribed suppura- 
tion between the dura mater and bone, or in the parts immediately internal 
to the dura mater, the question of aiding its escape will naturally present 
itself. If, therefore, the patient have a scalp wound, or be suffering from 
fracture, necrosis, or syphilis of any part of the skull, it will probably be 
deemed advisable to apply the trephine. If the source of mischief be the 
ear, that organ must be carefully examined ; if there be evidence of accu- 
mulation of matter in the tympanum, the membrane, assuming it to be 
whole, should be punctured or incised ; if it be already perforated and the 
discharge offensive, the cavity should be washed out carefully with anti- 
septic solutions ; if there be evidence of suppuration in the soft parts about 
the mastoid process, or behind the angle of the jaw, a free incision should 
be made ; and, further, if we have reason to suspect the presence of pus 
in the mastoid cells, these should be laid open by the trephine. But the 
inflammation is not always suppurative ; and the application of leeches 
over the mastoid process or in its vicinity often affords relief, especially in 
the early stage of the disease, and may possibly tend to arrest its progress. 
Hot fomentations and poultices to the part are not unfrequently grateful to 
the patient, and they may be rendered more so by the addition to them of 
opium, belladonna, aconite, or other preparations having sedative proper- 
ties. Evaporating lotions or ice to the head also are generally serviceable. 
As regards internal treatment, it is well in the first place to maintain free 
action of the bowels, and to restrain as far as possible sickness or other 
distressing symptoms. Iodide of potassium may also be administered. 
There is a general feeling against the employment of narcotics in these 
cases ; we must declare, however, that we have often seen much relief to 
agony and restlessness afforded by the exhibition of largish doses of laud- 
anum or morphia, and never any injurious consequences. If the affection 
take a chronic or subacute course, it may be well to administer iron, pre- 
ferably perhaps the syrup of the iodide, or quinine, or cod-liver oil, and 
to have recourse to counter-irritants. The patient should of course be 
kept extremely quiet, and be carefully watched, and his diet and secretions 
should be regulated. 

• 2. The treatment of cerebral pachymeningitis is that of old paralysis 
and other chronic organic lesions of the brain. 

3. For the local treatment of general acute inflammation of the theca 
vertebralis, leeching, fomentations, the application of ice and counter- 
irritation may be enumerated ; but more important perhaps than any of 
these is the maintenance of the patient at perfect rest, either on his back, 



868 



DISEASES OP THE NERVOUS SYSTEM. 



or in a position midway between the back and side. Iodide of potassium 
may be administered here as in the former case ; but tonics, stimulants, 
and opium are more likely to be of service. 

4. Paraplegia from vertebral caries must be treated by absolute rest in 
the supine position, on a bed specially adapted to the case, and with suit- 
able arrangements for the discharge of the patient's evacuations without 
the need of movement. And this rest must be maintained for a con- 
siderable period ; indeed, as has already been remarked, a period of one 
or two years or more may elapse before even a trace of returning muscular 
power can be observed. In addition, counter-irritation to the neighbor- 
hood of the part affected appears often to be of essential service ; the best 
forms are issues, which should be kept open, or the actual galvanic cautery, 
applied on one or both sides of the spine. The general health of the 
patient should be maintained by good diet, stimulants, and tonics ; and 
great care should be taken to prevent the supervention of bed-sores and of 
inflammation of the bladder. If the muscles show signs of wasting from 
disuse, the employment of faradism or of the direct current may be had 
recourse to — a treatment which may also be beneficial in promoting re- 
covery when recovery is in progress. 

5. Spinal pachymeningitis should be treated on the same principles as 
paraplegia from caries. 



III. CEREBRAL AND SPINAL MENINGITIS. TUBERCULAR 
MENINGITIS. {Acute Hydrocephalus.) 

Causation The causes of meningitis are various. In some cases it 

depends on the spread of inflammation from adjacent parts — from the 
brain or cord, from the dura mater or the bones, and more especially from 
the internal ear ; indeed the latter affections rarely produce cerebral 
symptoms without involving the pia mater to some extent. In some cases 
it is secondary to the presence of adventitious products, such as miliary 
tubercles, tumors, and apoplectic clots. It may be the result of injury or 
of direct exposure to the rays of the sun. It is sometimes of idiopathic 
origin, sometimes due to pyaemia, and sometimes (as apparently in epi- 
demic cerebro-spinal meningitis) produced by contagion. Tubercular 
meningitis, which is in fact by far the most common form of cerebral 
meningitis, may occur at any date between early infancy and old age. It 
probably, however, occurs most frequently before puberty ; but is common 
up to thirty. 

Morbid anatomy — I. Cerebral meningitis is characterized essentially 
by dilatation and hyperemia of the vessels of the pia mater, and the 
effusion of coagulable lymph and inflammatory corpuscles into the meshes 
of the subarachnoid tissue. The first naked-eye evidence of inflammation 
is the presence of congestion, which often assumes a patchy character ; to 
this opaline effusion into the subarachnoid tissue succeeds ; and presently 
the corpuscular and other solid products accumulate, at first more espe- 
cially on either side of the larger superficial veins, whence they gradually 
creep over the surface of the convolutions and into the depths of the sulci. 
In some cases the yellowish or greenish opaque exudation here referred to 
occupies mainly the prismatic intervals situated between contiguous con- 



MENINGITIS. 869 

volutions and the visceral layer of the arachnoid; in some, where it has 
| spread to a greater or less extent over the convexity of the convolutions, 
the surface of the brain becomes mapped out into a series of rounded or 
irregular congested areas, separated from one another by an irregular net- 
work of inflammatory exudation ; in some cases again, the accumulation 
j is so considerable that the surface is uniformly covered with it, and the 
sulci are widely distended. This exudation, which is often solid like an 
J ordinary false membrane, occasionally becomes distinctly purulent. The 
i inflammatory process, which is limited mainly to the substance of the pia 
mater and to the subarachnoid tissue, nevertheless affects to a greater or 
! less extent the neighboring arachnoid on the one hand, and the cortex of 
I the brain on the other. The accumulation in the subarachnoid tissue 
tends to expel the fluid from the arachnoid cavity; and, in cases of 
extensive inflammation, this fluid wholly disappears, and the surface of 
j the brain becomes more or less sticky and almost dry. The actual 
j appearance in such cases of inflammatory products on the free surface of 
I the arachnoid or within its cavity is rare. The intimate connection 
subsisting between the vessels of the pia mater and those of the cerebral 
| cortex renders it almost essential that these should share to a greater or 
less extent in any process which involves the former. And to a certain 
extent they do thus share : they become dilated and congested, and more 
or less inflammatory change takes place in the brain-tissue inclosed within 
their meshes. 

Inflammation may involve any part of the pia mater, and may spread to 
any extent over it; indeed meningitis, like erysipelas and many other 
forms of inflammation, has a marked tendency to diffuse itself superficially. 

I Sometimes, however, it occupies mainly the convexity of the hemispheres ; 
sometimes mainly the base of the brain ; sometimes mainly the surface of 
the cerebellum, pons Varolii and medulla oblongata. In the last case the 
inflammation usually spreads to a greater or lesser extent along the spinal 
cord. It frequently also involves the velum interpositum and choroid 
plexuses ; and probably on this account, the lateral ventricles usually get 
distended with fluid. Further the ependyma of the ventricles is often 
rough from the presence of minute granulations, and the white matter 
around the ventricles is often found reduced to a pulp. 

2. Meningitis due to tuberculosis nearly always begins at the base of the 
brain, is often limited to the base, and is generally most intense there. It 
differs anatomically from simple meningitis in the presence of gray miliary 
tubercles, varying from the size of a pin's head downwards. These may 
be so few in number or so minute as almost to defy detection ; they may 
be so abundant as to form large granular clusters, or irregular, cheesy 
patches of considerable extent and thickness. They commence in connec- 
tion with the arterioles whose channels they soon obliterate, and hence 
congregate especially along the vessels. They are found mainly in the 

[ neighborhood of the circle of Willis, extending thence along the fissures of 

! Sylvius to the lateral aspects of the hemispheres, around the crura cerebri 
into the great transverse fissure of the brain, and thence to the velum in- 
terpositum and choroid plexuses, and also over the pons Varolii. But they 
are not limited to these situations. They seldom involve the visceral arach- 
noid, or appear on its free surface ; they tend, however, to become developed 
in connection with the small vessels of the cortex, so that if the pia mater 

| be torn away a greater or smaller number of these vessels with tubercles 
in their walls are often also torn away, together with portions of the corti- 



! 



870 



DISEASES OF THE NERVOUS SYSTEM. 



cal matter itself. Not unfrequently, indeed, masses of tubercles at the 
bottom of the sulci appear to be imbedded in the substance of the brain. 
Minute superficial hemorrhages are not uncommon in this condition. When 
tubercles are few and small, they may sometimes be recognized by the 
finger as minute hard granules, or be seen on holding up detached laminae 
of pia mater to the light ; or they may need the microscope for their dis- 
covery. 

3. Spinal meningitis corresponds essentially in all its characters to the 
description which has been given above ; moreover, the presence of tuber- 
cles here is not unfrequent. They occur especially, Dr. Greenfield tells 
us, over the cervical and lumbar enlargements and on the inner surface of 
the dura mater. 

Symptoms and progress. — 1. Cerebral meningitis. It is impossible to 
make any practical clinical distinction between simple and tubercular 
meningitis ; we shall include them, therefore, in a common description. 
Meningitis, especially when it occurs in children, is said generally to be 
preceded by premonitory symptoms which may vary in their duration from 
a week or two to some months. They are probably only observed in cases 
of tubercular meningitis, and are referable in some degree to the fact that 
tubercles are already in process of development in the meninges, and in 
some degree perhaps to the presence of these bodies in other organs, such 
as the lungs, bowels, and serous membranes. The premonitory symptoms 
are variously described, and the majority of them have no distinctive 
characters. The child perhaps becomes emaciated, weak, and pallid, loses 
his appetite, suffers from constipation, is irritable, fretful, sad, indisposed 
to play, drowsy in the daytime, and wakeful at night, his sleep being 
attended with startings and grinding of the teeth, and disturbed by dreams, 
from which he wakes up frightened and screaming. He may suffer also 
from febrile disturbance. Amongst other occasional premonitory symptoms 
may be mentioned some of those which belong to the earlier stages of the 
established disease, especially vertigo, headache, squinting, sickness, and 
slowness with irregularity of pulse. 

The symptoms of invasion, whether preceded by prodromata or coming 
on without them, are exceedingly various. The patient complains : in 
some cases of pain across the temples, through the eyes, or elsewhere in 
the head, which is more or less persistent, but liable to paroxysmal exacer- 
bations ; in some of vomiting, coming on frequently, without apparent 
cause and not necessarily attended with marked impairment of appetite ; 
in some of fever of irregularly remittent type, attended, it may be, with 
more or less severe rigors ; in some of double vision. Sometimes the first 
indications of disease are furnished by more or less dulness, strangeness, 
or wildness of manner, by impairment of memory or defect of speech, or 
by the collective symptoms which characterize the early stage of delirium 
tremens. Sometimes the attack is ushered in by an epileptic seizure. 

The progress of the disease is usually divided into three stages, which 
in typical cases are often fairly well marked. The first stage, which 
includes the invasion, is generally characterized by fever, elevation of 
temperature, increased rate of pulse, and the phenomena of nervous irrita- 
tion ; the second stage is usually attended with diminution or cessation of 
fever, slowness of pulse, or the phenomena of commencing paralysis ; the 
third stage, or that of collapse, is the stage usually of convulsions and 
coma, during which also febrile symptoms not unfrequently again manifest 
themselves and the pulse becomes extremely rapid. 



MENINGITIS. 



871 



The first stage is ushered in for the most part with various combinations 
of the symptoms which have been above enumerated, and is generally 
attended with elevation of temperature — febrile exacerbations, often asso- 
ciated with rigors, coming on irregularly and sometimes several times a 
day; acceleration alternating with slowness of pulse; headache, which is 
often so severe that the patient screams out with it or supports his head 
with his hands, and which is not unfrequently associated with tenderness 
of the scalp and neuralgic pains in the back of the neck, extending, it may 
be, to the limbs; nausea, and more or less uncontrollable vomiting; con- 
stipation; disturbed sleep or sleeplessness; sadness and taciturnity, or 
querulousness, or tendency to delirium. To these symptoms are not 
unfrequently added hyperesthesia, tremulousness, and muscular debility, 
intolerance of light and sound, hemiopia, illusive appearances, double 
vision or squinting from spasm of the muscles of the eyeballs, and con- 
tracted pupils. In this stage young children are generally fretful, peevish, 
agitated at the approach of strangers, and resentful at the attentions of the 
nurse or mother, and not unfrequently even now utter the characteristic 
hydrocephalic cry. 

In the second stage the patient becomes comparatively quiet, and passes 
into a drowsy condition ; his temperature for the most part falls somewhat, 
and though generally still a degree or two above the normal, may sink to 
the normal or even below it ; and his pulse becomes slower than natural, 
and at the same time more or less irregular. The transition from unrest 
to rest, and the subsidence of fever give a delusive aspect of convalescence.. 
In this stage the cephalalgia, the exaltation of the senses of sight, hearing, 
and touch, the nausea and sickness, and the irritability of temper, or sad- 
ness, or moroseness, all subside, and the patient becomes apathetic. He 
perhaps sleeps continuously, and is roused with difficulty to put out his 
tongue or take nourishment ; he probably does not refuse food, but he does 
not ask for it ; nor does he trouble himself to restrain his evacuations. 
His breathing, like his pulse, is irregular, and characterized by a series of 
rapid respirations followed by long intervals of complete apnoea. It is 
during this period that certain other phenomena are peculiarly apt to be 
present — to come on for the first time, or to undergo aggravation. The 
hydrocephalic cry, in children especially, now becomes a marked feature 
of the case ; it is uttered at frequent but irregular intervals. The following 
is Trousseau's description of it: ' He groans from time to time, opens his 
eyes wide, which shine as they do in persons who are drunk. His face, 
which is usually extremely pale, flushes for a second or two ; then he closes 
his eyes again, and resumes his former aspect. Generally, as he thus 
opens his eyes, and as his face colors up, the child utters a sharp plaintive 
cry, which is perfectly characteristic' The face, which is generally pallid, 
is liable to sudden temporary flushes, and the tache cerebrale is easily pro- 
duced. Retraction of the abdomen is almost always present. During 
this stage the patient is apt to roll his head from side to side, to move his 
hands and arms restlessly, to wave them or throw them about, to pluck at 
the bedclothes, or to pick his nose, lips, or ears, and to perform various 
other movements ; he may suffer from quiet delirium, or present partial 
convulsive movements of his face or limbs ; his pupils may get dilated or 
unequal, and irresponsive to light; sight may fail; and paralysis may come 
on, especially ptosis, paralytic strabismus, paralysis of the portio dura or 
hypoglossal, or hemiplegia. 

The third stage is characterized by the supervention of convulsions and 



872 



DISEASES OF THE NERVOUS SYSTEM. 



coma, or of coma alone. The patient, who could hitherto be roused with 
more or less ease, now scarcely responds to any external influence. He is 
anaesthetic, deaf, blind, the pupils are dilated, probably unequal, and react 
slowly or not at all to light. Sometimes inflammation or ulceration of the 
cornea takes place. Paralysis has become more pronounced either in cer- 
tain muscles or groups of muscles, or on one side of the body. He still, 
however, rolls his head about; still has subsultus or tremors, or picks at 
the bedclothes; still utters the distressing cry peculiar to the disease. The 
respirations get more frequent and irregular. The pulse may still remain 
below the normal rate, but more usually becomes exceedingly rapid and 
feeble. The temperature for the most part rises, especially in the internal 
organs ; that is to say, the limbs get cold and dusky, while the trunk and 
viscera are burning hot. But the temperature during this stage is liable 
to great variety ; in one case it rises rapidly as death approaches ; in 
another it remains elevated two, three, or four degrees above the natural 
standard ; while in yet another it falls 10 or 15 degrees or more below it. 
The cheeks are alternately pale and flushed,, and the surface bathed in 
sweat. The tongue, which during the earlier stages may have been 
r atural, or may have presented more or less whitish fur upon its surface, in 
the third stage generally becomes thickly coated, dry, and brown, and the 
teeth get covered with sordes. Convulsions, as a rule, are now frequent, 
sometimes incessant, sometimes slight, sometimes violent, sometimes limited 
to the face or to the hands, sometimes unilateral, sometimes general. They 
are apt to increase in severity as the fatal end approaches; and the patient, 
who always dies comatose and sometimes collapsed, is not unfrequently 
carried off in a convulsion. 

In addition to the delusive appearance of amendment which character- 
izes the beginning of the second stage, it is not uncommon, towards the 
close of the second or beginning of the third stage, for the patient to wake 
up as it were from his semi-coma or coma, to recognize his friends, and to 
take an interest in what is going on around him. The amendment may 
last a day or two, and may recur, and is apt not unnaturally to raise the 
hopes both of the friends and of the medical attendant. Unfortunately, 
however, these hopes are, almost without exception, doomed to speedy 
disappointment, and sooner or later all the symptoms return, become aggra- 
vated, and death ends the scene. It is nevertheless a fact not only that 
temporary recovery occasionally takes place, but that patients who present 
distinct symptoms of meningitis now and then recover permanently. 

The duration of cerebral meningitis is very uncertain. It is generally 
from one to three weeks, and not unfrequently about a fortnight. It may 
be only three or four days. The different stages also which have been 
enumerated vary in duration, both actually and relatively, and in all cases 
the transition from one to another is quite gradual. 

It must never be forgotten, however, that although there is a common 
tendency for the progress of meningitis to divide itself into successive 
stages, and although these successive stages have a tendency to assume 
such characters as have been above assigned to them, in a very large pro- 
portion of cases the symptoms and progress of the disease diverge widely 
from the type. No disease, indeed, is more protean in its features than 
meningitis, probably none simulates so many other disorders. In some 
cases, as for example when meningitis complicates acute pneumonia, ery- 
sipelas, or other inflammatory affections, the only indication of what proves 
to be extensive meningitis may be the supervention of drowsiness, coma, 



MENINGITIS. 



873 



and collapse during the day or two preceding death. In some cases, in- 
deed, even when the inflammation of the brain is uncomplicated, drowsi- 
ness and coma are the only symptoms ever recognized. In many cases the 
early stage of the disease is mistaken for inebriation or delirium tremens; 
and indeed the symptoms of meningitis are not unfrequently, during the 
greater part of its duration, almost exact counterparts of those of delirium 
tremens. In other cases the symptoms have a close resemblance to those 
of enteric fever, and in children to that vague and uncertain malady which 
is commonly termed 1 gastric fever' — especially to those cases of these 
affections in which the accustomed diarrhoea is replaced by constipation, 
and the abdomen fails to present its ordinary flatulent distension, while at 
the same time nervous phenomena, such as headache, sleeplessness, irrita- 
bility, and delirium prevail. In other cases, again, meningitis presents 
many of the features of general tuberculosis ; it must be recollected, how- 
ever, that general tuberculosis is very apt to be attended with involvement 
of the surface of the brain, and that hence the supervention of meningitis 
in the course of the general disease should not be overlooked. Sometimes 
the patient, from the commencement of his malady up to the occurrence 
of coma, is in a condition of mild delirium ; occasionally, but much more 
rarely, he is in a state of maniacal excitement; sometimes epileptic con- 
vulsions predominate : sometimes he is sensible from first to last. In some 
instances headache and vomiting never present themselves ; in some dis- 
tinct paralysis never occurs; in some paralytic phenomena form the most 
striking features of the malady. The hydrocephalic cry may never be 
uttered. 

Still, however obscure the case may be, there is almost ahvays some- 
thing during its progress which reveals to the observant practitioner its 
fatal character. The cloven hoof shows itself. There is vomiting without 
obvious cause, or fever of a certain character, or retraction of the head, or 
hyperesthesia ; or there is some affection of the pupils, or some temporary 
or permanent paralysis, even though it be limited to the levator palpebras 
or one of the ocular muscles; or there is some convulsive movement, or 
the characteristic distressful cry, or some peculiar change in the mental 
condition; or the respirations are characteristically irregular; or the mus- 
cular debility or tremulousness are out of all proportion to the other 
symptoms exhibited. Further, optic neuritis is frequently present, even 
from the earliest period of the patient's illness ; and generally also Trous- 
seau's tache cerebrale, a phenomenon, however, of little importance, can 
be readily developed. It consists in the speedy appearance and long dura- 
tion of a comparatively wide blush of redness in the course of a line made 
by drawing the finger-nail or the point of a pencil along the skin, more 
especially on the face, abdomen, or inner aspect of the thigh. Since the 
larger number of cases of meningitis are of tubercular origin, accuracy of 
diagnosis may often be insured by careful attention to the history of the 
patient and by careful examination of his lungs and other organs in refer- 
ence to the presence of tubercular disease in them. Occasionally tubercles 
may be recognized in the choroid. 

The great variableness of the phenomena which attend meningitis be- 
comes easy of explanation when we look to the morbid anatomy of the 
disease and consider how many parts are liable to suffer, and how un- 
equally they may be involved. We have seen that the morbid process, 
especially if it be of tubercular origin, is peculiarly apt to invade the 
cortical substance of the brain. What wonder that mental phenomena 



874 



DISEASES OF THE NERVOUS SYSTEM. 



and convulsions should ensue, and that these should vary largely in their 
details in different cases ? We have seen how almost invariably the base 
of the brain suffers more than other parts, and how the nerves are conse- 
quently liable to be involved in the inflammatory process. What wonder 
that hyperesthesia and paralysis, variable as to their seat and degree, 
should be present ? We have seen that the lateral ventricles are apt to 
get distended with fluid, their parietes softened and compressed. Is it 
remarkable that, when these changes take place, coma and paralysis are 
of common occurrence ? 

2. Spinal meningitis. — The symptoms of acute inflammation of the 
spinal pia mater differ but little from those which have been ascribed to 
inflammation of the theca vertebralis, and necessarily have some resem- 
blance to those developed in the course of myelitis. Indeed, many of the 
symptoms which occur in inflammation of the dura mater are really due 
to the extension of disease to the pia mater ; and many of those of inflam- 
mation of the pia mater are essentially referable to involvement of the 
subjacent nervous matter. 

When any considerable length of pia mater is affected, more or less fever 
of a remittent character, and possibly attended with rigors, will very likely 
be present. There will probably also be anorexia, thirst, and abnormal 
rapidity of pulse. Sometimes, however, the pulse is slow. The patient 
most likely complains of pain in the course of the spine, not much increased 
by simple pressure, but greatly aggravated and sometimes amounting to 
unendurable agony when either muscular movements are performed or the 
spinal column is bent or twisted. There is generally more or less rigidity 
of the voluntary muscles — the muscles of the back, and more especially 
those of the neck, being chiefly affected, and the head consequently re- 
tracted ; the elbows are apt to stand out from the body, and the forearms 
and hands to be somewhat flexed ; the lower extremities are probably 
similarly affected ; the jaws are often firmly closed, and the muscles of the 
face contracted so as to give to the expression the well-known risus sar- 
donicus. Further, sudden twitches and spasms of a tetanic character are 
apt to occur from time to time, not only in the muscles of the back, which 
becomes consequently a little more arched, but in those of the limbs and 
head and neck. At the same time the patient complains of pain, not 
merely in the back, but also in the head, and especially in the extremities, 
into which it shoots in sudden paroxysms, which are excited whenever he 
executes any movement, or his muscles are forcibly disturbed by the hands 
of the attendant. There is not unfrequently also some hyperesthesia. 

Partly mingled with these phenomena, but more especially supervening 
upon them, is impairment of voluntary movement and sensation ; the pa- 
tient loses more and more the power over those limbs which correspond to 
or are below the seat of lesion, and he loses also, in a greater or less degree, 
control over the rectum and bladder. Indeed incontinence of urine and 
feces is apt to to take place even when paralysis of the voluntary muscles 
is very slight, and while at the same time the patient's mental faculties 
appear to be intact. Tingling, formication, or numbness is not unfre- 
quently present. If the disease involve the higher part of the spinal pia 
mater and that of the medulla, difficulty of respiration, speech, deglutition, 
and mastication may be present. Priapism and increased irritability of 
the excito-motor functions are rarely observed. Vertigo, headache, slight 
delirium, and other cerebral phenomena generally arise in the course of the 



MENINGITIS. 



875 



malady, especially if the meningitis extend from the spine to the base of 
the brain. 

The main features of the disease appear to be : pain, more or less intense, 
along the spine and shooting into the extremities, especially aggravated 
by movement ; hyperesthesia ; rigidity with occasional spasmodic contrac- 
tion of the voluntary muscles ; and more or less want of power over the 
rectum and bladder. Absolute paralysis is rare, and absolute anaesthesia 

! still rarer. Indeed the patient, who has probably been for some days con- 

1 fined to his bed, apparently unable to move, and suffering agony when 
involuntary or other movements are effected, and exerting no control what- 
ever over his evacuations, will sometimes suddenly, in his restlessness, 

I agony, or delirium, sit up in bed, or even get out of bed and pace the 

! room. 



The commencement of the disease, especially if it be secondary to any 
other serious malady, is often insidious and obscure. And even when it is 
of purely idiopathic origin, the symptoms may be so slightly pronounced 
during the first three or four days that the patient refuses to go to bed, 
and in some cases goes on with his usual avocations. The initial symp- 
toms are not unfrequently more or less pain, usually supposed to be rheu- 
matic, in the course of the spine and of the nerves which are given off 
from it, increased by movement, and attended with febrile disturbance, 
restlessness, irritability of temper, and sleeplessness. 

Spinal meningitis is a very fatal malady, and although doubtless some 
persons recover from it, the great majority die, succumbing for the most 
part between the third or fourth day and the third or fourth week. Most 
deaths, however, occur within the week, and are due either to asphyxia 
or to asthenia, the latter often being promoted by the rapid supervention 
of bed-sores and other complications. 

Treatment.- — Cerebral meningitis for the most part defies all medical 
treatment ; still, as recovery certainly takes place occasionally, even when it 
is of a tubercular origin, it behooves us to give some care to the management 
of all cases of the kind that come under our charge. The patient should 
be placed in a room sufficiently darkened to be grateful to his irritable 
eyesight, sufficiently quiet to prevent all auditory disturbance, and at the 
same time cool and well-ventilated. He should be carefully watched by 
a quiet and judicious attendant. Everything indeed should be done to 
avoid the infliction of discomfort on the hyperaesthetic senses, to calm 
irritability, and to promote rest. If the limbs be cold, they should be 
kept at an equable temperature by means of flannel or other warm cloth- 
ing. The headache which is so often present may be relieved by the tem- 
porary application of evaporating lotions, or ice, to the forehead or shaven 
scalp ; and it may for the same and other purposes even be advisable to 
apply leeches behind the ear, or blisters or other counter-irritants to the 
temples, scalp, or back of the neck. Leeches, however, should only be 
applied early in the disease. The number to be employed, and the amount 
of blood to be removed, must be determined partly by the age of the pa- 
tient, partly by the other circumstances of the case. Thus, if the menin- 
gitis occur in a healthy-looking adult, free removal of blood even by vene- 
section will be well borne, and may be highly beneficial. In a young child 
two or three leeches are generally ample. The relief of head symptoms 
is often attended with alleviation of sickness. But this may sometimes 
be treated directly with advantage by the administration of either ice, 
bismuth, hydrocyanic acid, oxalate of cerium, or other remedies which 




876 



DISEASES OF THE NERVOUS SYSTEM. 



are ordinarily given to assuage sickness. It is generally highly important 
to keep the bowels freely open, and this (in consequence of the extreme 
obstinacy of the constipation) is sometimes exceedingly difficult to effect. 
Enemata may be resorted to ; but it is generally better to give purgatives 
by the mouth, and especially to give those which are not likely to upset the 
stomach. Sir T. Watson recommends as the best purgatives for children 
calomel and jalap, or calomel and scammony. Castor oil also generally 
agrees well with children. In the case of adults purgation should be actively 
employed. Amongst special remedies, may be enumerated : first, simple 
saline or febrifuge medicines, which doubtless have little efficacy ; and 
second, iodide of potassium, which is probably advocated rather on theo- 
retical grounds than from actual experience of its value. Opium is gene- 
rally considered to be contraindicated ; we must confess, however, that we 
have not unfrequently administered it during the earlier stages of menin- 
gitis, not only without obvious injury to the patient, but with manifest 
relief to his irritability and insomnia. Fluid nutriment should be admin- 
istered in small quantities, and at frequent intervals. 

Prophylactic measures are of paramount importance in the case of either 
children or adults in whom there is reason to fear the supervention of 
meningitis. Their studies or other mental labors should be intermittent ; 
they should be kept quiet, in mind and body, should keep early hours, be 
removed (if need be) to some healthy locality, occupy well- ventilated 
rooms, have ample wholesome nourishment, and be placed under a course 
of cod-liver oil and tonics. Further, all their functional disturbances 
should have due attention paid to them, sickness should be obviated, con- 
stipation overcome. 

Adults as a rule may be treated far more actively than children, and 
those who are non-tubercular far more actively than those who are tuber- 
cular. For such patients the main remedies during the attack consist in 
cold to the head, leeching behind the ears, and active purgation. 

As regards the treatment of spinal meningitis, it is essential : that the 
patient be kept in the recumbent posture on a suitable bed ; that he be kept 
scrupulously clean and dry ; that all parts liable to bed-sore sbe defended 
from the effects of pressure ; and that the condition of his bladder and 
bowels be carefully watched, and the bladder, if necessary, relieved period- 
ically by the catheter. In other respects the remedial measures to be em- 
ployed are the same as those which are supposed to be serviceable in cere- 
bral meningitis. 



IV. ENCEPHALITIS AND MYELITIS. 

Inflammation and Suppuration of the Brain and Cord. 

Causation. — The circumstances which determine acute inflammation in 
the brain and cord are, like those which cause inflammation elsewhere, very 
various. In most cases it is due to extension from without : speading di- 
rectly from the pia mater, or (in those cases in which pus is extravasated 
into its cavity) from the arachnoid ; or following upon inflammation orig- 
inating in the dura mater or the bones of the skull or spine ; or referable 
to the direct spread in depth of erysipelatous and other like affections of 
the skin and subjacent tissues. In a large number of cases encephalitis or 



ENCEPHALITIS AND MYELITIS. 



877 



myelitis arises from the influence of some irritating mass, such as a clot, 
tumor, parasite, or patch of softening situated in the nervous substance or 
implicating it from without. It is a common consequence of injuries, even 
if these be unattended with fracture. It is sometimes referable to pysemia. 
And occasionally it seems to be an idiopathic affection, due to exposure or 
to causes which we fail to recognize. 

Morbid anatomy 1. Encephalitis. There is no reason to doubt that 

inflammation occasionally involves the great bulk of the brain, as it cer- 
tainly sometimes does the whole thickness of the cord in no inconsiderable 
proportion of its length. The cases in which this phenomenon is believed 
to have been present are those in which the general substance of the brain 
has been found after death much congested and softened, and in which the 
inflammatory process if present at all must have been in quite its initial 
stage. The condition, in fact, has differed little from what is seen in gene- 
ral congestion of the organ, as it is sometimes observed in fatal cases of 
epilepsy, delirium tremens, or sunstroke. In most cases of encephalitis 
the inflammation is of limited extent, occupying sometimes tracts of gray 
matter, sometimes tracts of white, and often involving portions of both. In 
some instances a single patch is present, in some there are several ; and their 
sizes and forms vary within wide limits. If, however, they be not deter- 
mined as to shape and extent by the fact of their being secondary to some 
clot or other adventitious mass, or to meningeal inflammation, they tend to 
assume a roundish or ovoid form, rendered more or less irregular by the 
configuration of the surface of the brain and the arrangement of its parts. 
The changes which mark the early stage of acute inflammation are more 
or less circumscribed congestion, effusion of fluid and other inflammatory 
products, and softening. The tissues of the affected part are swollen and 
pulpy, and generally admit of being readily washed away under the impulse 
of a stream of water, leaving a shreddy excavation behind. The redness 
is more or less intense according to the quantitative relation the congested 
vessels have to the amount of exudation, and is generally patchy. Some- 
times small extravasations of blood occur. Further, more or less conges- 
tion and oedema, together with some yellowness of tint, may generally be 
observed in the surrounding tissues. 

With the progress of the inflammatory process, exudation-corpuscles 
or pus-cells accumulate in the affected district, which gradually loses its 
congested aspect and gets yellowish or greenish, and less and less con- 
sistent. Presently the central portion becomes diffluent, and an abscess 
forms ; the pus of which is thick, glairy, yellowish or greenish, and 
occasionally offensive, and the parietes of which are constituted by the 
still solid but soft and breaking down tissue. Occasionally the abscess 
becomes encysted, the capsule sometimes attaining a thickness of a quarter 
of an inch. The microscopical characters of the inflamed patches vary 
somewhat according to the stage at which the process has arrived. In the 
earlier periods there may be observed : vascular changes with accumula- 
tion of leucocytes in the perivascular sheaths ; more or less destruction of 
the nervous elements — the myeline of the nerve- tubules breaking up into 
globules of various sizes ; and a greater or less development of granule- 
cells. Somewhat later, the degenerating tissue becomes loaded with pus- 
corpuscles. In the fully-formed abscesses, the puriform matter is not 
unfrequently found devoid of pus or other cells, and comprising only fatty 
matter and debris of tissues. 

Abscesses of the brain are not of very frequent occurrence, and are 



878 



DISEASES OF THE NERVOUS SYSTEM. 



mostly solitary. When multiple, they are almost invariably pyemic. 
The abscesses of most interest to the physician are those which are 
secondary to disease of the ear, nose, orbit, or other parts of the skull. 
When secondary to ear-disease, they occur either in the adjoining part of 
the middle or posterior cerebral lobe, or in the corresponding lateral lobe 
of the cerebellum, or somewhat more rarely in the pons Varolii. In most 
instances the surface of the bone is carious, the dura mater over it is 
softened and inflamed, and the abscess is situated in a diseased patch of 
brain, which has become adherent ; but occasionally the dura mater re- 
mains apparently healthy, and the abscess moreover is separated from the 
surface by a layer of healthy-looking brain-substance. The explanation 
of this fact is not clear ; but it is generally assumed to be due to the 
plugging up of some of the vessels passing from the sinuses into the 
substance of the brain, or to the extension of inflammation along them. 
According to Sir W. Gull's and Dr. Sutton's statistics, it appears that 
abscesses occur equally on both sides of the brain ; and that, although any 
part may be their seat, they are most common in the middle cerebral 
lobes. The presence of an abscess of medium or large size in the sub- 
stance of the brain causes more or less general enlargement of the lobe or 
part in which it occurs, with flattening of the surface of the brain over it 
and in its vicinity, obliteration of the sulci, and displacement of the sub- 
arachnoid fluid. An occasional result of abscess is its extension, by 
bursting or by gradual erosion, into the cavity of the arachnoid, or into 
one of the ventricles, or its discharge externally through the ear or nose. 

2. Myelitis, — Inflammation of the substance of the cord is attended 
with similar changes to those above described. When secondary to 
disease of the membranes it first involves the white substance, and only 
subsequently, and at a comparatively late period, extends to the central 
gray columns. Idiopathic inflammation, however, mostly affects primarily 
and principally the gray matter. It results in softening of the nervous 
tissues, with a much more marked liability to the extravasation of blood 
than attends cerebral softening; indeed, in Charcot's opinion, hemorrhage 
(however copious) into the substance of the cord is mostly, if not always, 
the result of previous inflammatory softening. Inflammation generally 
tends to implicate the whole thickness of the cord, and, though frequently 
limited to comparatively short lengths of it, not very uncommonly involves 
extensive tracts. Actual abscesses are of rare occurrence. 

Symptoms and progress. — 1. Encephalitis. The symptoms which 
may be referred to inflammation of the brain-substance extend no doubt 
over a wide range. Indeed, it is unquestionable, as has already been 
pointed out, that many of the symptoms of cerebral meningitis are really 
due to implication of the subjacent gray matter. Further, these condi- 
tions are so generally combined that it would be a mere waste of space and 
of ingenuity to endeavor to make any absolute distinction between them. 

Of acute general inflammation of the encephalon, there is little to be 
said. The cases are rare, the symptoms which they present are vague, 
and the morbid changes which are observed after death are, to say the 
least, obscure. They are mostly of rapid progress, and attended, as Dr. 
Wilks observes, with more or less severe pyrexia, delirium, dulness of in- 
tellect, and final coma, but perhaps no other symptoms specially referable 
to the brain. Occasionally there is a preliminary stage in which, as he 
says, the patient may suffer from headache, sickness, slow pulse, and con- 
stipation. It need scarcely be observed that these are symptoms which 



ENCEPHALITIS AND MYELITIS. 



879 



are not unfrequently met with in cases of sunstroke, and occasionally in 
persons who have been indulging continuously, for some days or weeks, in 
excessive drinking. 

The symptoms which attend inflammation secondary to the presence of 
apopleetic clots, patches of softening, tumors, and the like, in the substance 
of the brain are also exceedingly vague. A little accession of fever, a 
little increase of headache or giddiness, a little failure of appetite, a little 
aggravation of the paralytic phenomena from which the patient has been 
suffering, a little impairment of intelligence, the occurrence of delirium, 
convulsions or coma, and perhaps the development of some rigidity in the 
affected limbs, some hyperesthesia, some pain in muscles or joints, or some 
tendency to the formation of bedsores on the affected side, separately or in 
combination, are the main indications of its supervention. 

The symptoms due to circumscribed inflammatory softening, or sup- 
puration, are not less vague and obscure than those which belong to the 
varieties of inflammation already considered. Among those which may be 
present are febrile disturbance with rigors, anorexia, vomiting, and con- 
stipation, vertigo, headache often occurring mainly at one spot, dulness, 
stupidity, delirium, coma, epileptiform convulsions, paralysis, affection of 
speech or of the special senses, and want of control over the bladder and 
rectum. In addition, few if any of the other symptoms which may be ob- 
served in cerebral meningitis may not at one time or another, or in certain 
cases, be present here. On the other hand, an abscess may be found en- 
cysted in some part of the brain-substance, which has existed there for 
weeks or months, possibly years, without giving any hint of its presence. 
It is obvious, indeed, when we consider the various sizes which inflamed 
regions or abscesses present,- the various positions which they may occupy 
in the substance of the encephalon, and the various lesions (pyaemia, dis- 
ease of the ear, and inflammation of the dura mater, pia mater, or both) 
with which they are apt to be associated, that the symptoms which accom- 
pany them must present the greatest possible variety. Thus, as regards 
febrile symptoms, there can be little doubt that the inflammatory process 
in the brain will usually be attended with more or less marked fever, and 
not improbably with rigors, but that these phenomena will certainly be 
aggravated if pyaemia be present, or if suppuration be taking place beneath 
the dura mater, or pus have escaped thence into the cavity of the arach- 
noid ; while, on the other hand, they may be entirely absent if the patch 
of inflammation be small, or if it pass into the chronic state, or form an 
encysted abscess. Again, pain is one of the most common symptoms of 
abscess of the brain : pain, various in character, often referred to a parti- 
cular spot, sometimes affecting the eyes, or shooting through the temples, 
or occupying the back of the head ; but pain may be absent from first to 
last, and generally, when it is present in any marked degree, is due rather 
to coexistent affection of the bones or dura mater than to the cerebral 
disease. Another frequent consequence of localized inflammation or ab- 
scess is paralysis or interference with the functions of one or other of the 
nerves of special or common sensation. But while it will be admitted that 
an extensive lesion will probably cause hemiplegia on the opposite side of 
the body, it is obvious that the presence of hemiplegia, and especially of 
affection of any one nerve, or group of nerves, will depend less on the size 
of the lesion than on its situation. If it be seated in the pons Varolii or 
medulla oblongata, a wide extent of paralytic affections of the spinal nerves 
will almost necessarily ensue, and respiration and deglutition be largely 



880 



DISEASES OF THE NERVOUS SYSTEM. 



interfered with. The importance, however, of analyzing the complex 
nervous symptoms which may be present, in reference to the facts of cere- 
bral localization, with the object of determining the locality of the lesion, 
is sufficiently obvious. The evidences of optic neuritis may often be ob- 
served in these cases. 

There are, indeed, no special symptoms or groups of symptoms the 
presence or absence of which will enable us to diagnose the presence or 
absence ot a patch of inflammatory softening or of an abscess in the brain. 
We have good reason, however, for suspecting the presence of such lesions 
when symptoms of the kind above enumerated supervene in the course of 
chronic otorrhoea, or of syphilitic or other forms of caries or necrosis of the 
bones of the skull, or upon injuries to the skull or brain. Yet, even here, 
the symptoms which we take to be indicative of cerebral abscess may be 
due to suppuration beneath the dura mater, with extension to the arachnoid 
or pia mater. 

The beginning of circumscribed inflammation or suppuration of the 
brain is sometimes marked by a sudden attack of convulsions, sometimes 
by unilateral or more limited loss of power or sensation, sometimes by 
cephalalgia with vertigo and vomiting, sometimes by impairment of intel- 
ligence, sometimes by fever. The pulse, as in other cerebral affections, is 
not unfrequently slow and irregular. The progress of the disease, like 
that of meningitis, may often be divided into a stage of irritation and one 
marked by impairment or abeyance of the functions of the nervous centres, 
passing into collapse. In the former we may observe vertigo, headache, 
intolerance of light, hyperesthesia, irritability, wakefulness, with perhaps 
delirium and vomiting; in the latter, disappearance of pain, paralysis, 
want of control over the action of the bladder and rectum, drowsiness, 
stupor, coma. Convulsions may occur at any time ; but, we repeat, the 
symptoms are variable in the highest degree, both as to their nature and 
the order of their succession; many who have abscess of the brain die 
without the presence of abscess having ever been suspected ; and many 
cases in which we venture to foretell that abscesses will be discovered,^ 
falsify our prediction upon the post-mortem table. Reckoning the dura- 
tion of cases from the time when acute symptoms indicative of brain dis- 
ease first manifest themselves, they may be said to prove fatal usually 
from the fifth or sixth day down to the end of the third or fourth week. 
Death is commonly preceded by coma, but may be due to asthenia or to 
asphyxia. 

2. Myelitis. — The symptoms of acute myelitis are, in the main, those of 
suddenly occurring paraplegia, and are therefore in many respects like those 
of spinal meningitis. They have a closer resemblance, however, to those 
M r hich follow upon fracture of the spine attended with injury to the cord. 
In considering the symptoms due to myelitis there are two or three con- 
siderations which it is important to bear in mind. In the idiopathic 
affection the inflammation affects primarily, and in the highest degree, the 
central gray matter of the cord ; hence it follows that sensation will pro- 
bably be at least as soon and as profoundly involved as motion. In menin- 
gitis, and other diseases affecting the cord from without, the white matter 
is mainly implicated, and motion is lost in far higher proportion than sen- 
sation. In myelitis there is a great tendency for the disease to diffuse 
itself throughout the length of the cord, and thus not merely to cause 
gradually ascending paralytic phenomena, but also to annul the reflex 
functions of the cord and the electrical contractility of a gradually increas- 



ENCEPHALITIS AND MYELITIS. 



881 



ing number of muscles. The result is different, as we know, when para- 
plegia follows any limited lesion of the thickness of the cord. In myelitis 
the profound involvement of the elements of the gray matter naturally 
tends rapidly to induce the peripheral nutritive consequences of spinal 
lesions, especially wasting of muscles, development of bed-sores on the 
sacrum and elsewhere, and inflammation of the bladder and kidneys. In 

j this respect especially idiopathic myelitis far more resembles the effects of 
serious accidental injuries to the spine and cord than any other form of 

! disease. Further, the gray matter of the cord is, so far as we know, in- 

1 sensible to pain, and lesions which directly involve it are also unattended 
with pain. Myelitis is not, therefore, usually a painful disorder; pain, 

■ indeed, in spinal affections is almost always the consequence of pressure 

j upon, or involvement of, the sensory nerves within the spinal canal, or of 
the posterior roots in their passage through the white matter of the cord. 

j Hence pain in the back, extending to the trunk or extremities, is much 
less likely to be due to myelitis than to meningitis, and, it may be added, 

1 less likely to be due to meningitis than to the growth of tumors or the 
extension of aneurisms. Lastly, twitchings and tetanic spasms of the 

: muscles are in no sense an indication of myelitis. They are common, 

i however, in meningitis. 

The symptoms of acute myelitis sometimes come on gradually in the 
course of a few days, sometimes manifest themselves with sudden inten- 
sity. A patient, perhaps after long-continued over-exertion, or exposure 
to the weather, or sleeping on the damp grass, or it may be during the 
progress of vertebral caries, is attacked in his toes and feet with numbness 
and tingling, which gradually extend upwards, and are succeeded after a 
varying interval by the progressive or almost sudden annihilation of sen- 
sation and voluntary motion in the lower extremities, and up to the level 
of a horizontal line which corresponds to the upper limit of the distribu- 
tion of the involved spinal nerves. The relative dates at which sensation 
and voluntary motion are lost vary in different cases, as also does the de- 
gree in which the corresponding limbs are involved. Nor does it neces- 
sarily follow that either sensation or motion is wholly abolished. There 
is not usually absolute pain, still less pain of a neuralgic character ; but 
there is often a more or less distressing sense of restlessness and tingling 
in the paralyzed limbs, and of constriction round the abdomen and chest. 
There may, however, be cutaneous hyperesthesia at the upper limit of the 
affected region. Twitchings of the paralyzed muscles may attend the earlier 
stages of paralysis ; but generally these soon cease, and the directly impli- 
cated muscles, as a rule, speedily lose their electric contractility, and be- 
come flaccid and lifeless. The muscles, however, thus affected are only 
those supplied by the diseased length of cord; they are hence few or many, 
according to circumstances; while all those which are supplied by nerves 
given off lower down retain this and their reflex excitability and their bulk, 
as in ordinary cases of paraplegia. Priapism is occasionally present ; the 
bowels are constipated, and the motions discharged unconsciously ; and 
there is either retention or incontinence of urine. Bed-sores, especially 
over the sacrum, are apt to arise, in spite of every precaution, sometimes 
within four or five days of the commencement of paraplegia ; and at the 
same time, even where the greatest care has been taken, the urine prob- 
ably becomes ammoniacal and the mucous membrane of the urinary tract 
inflamed. 

It need scarcely be added that the distribution and extent of the para- 
56 



882 



DISEASES OF THE NERVOUS SYSTEM. 



lytic phenomena will be determined by the position and extent of the disease ; 
that there will be involvement of the lower limbs only when the disease 
occupies the mid-dorsal region ; of the upper and lower extremities when 
the cervical enlargement is included ; hemi-paraplegia when one side of the 
cord mainly suffers ; difficulty of respiration when the intercostal nerves 
are implicated; asphyxia when the origins of the phrenic nerves are also 
involved. In the last two cases difficulty of speech and inability to dis- 
charge accumulating mucus from the bronchial tubes add seriously to the 
patient's sufferings. 

It must not be forgotten that, although cerebral symptoms, neuralgic 
pains, and spasmodic action of the muscles are no necessary parts of 
myelitis, they are not uncommonly superadded in consequence of the 
coexistence of some degree of meningeal inflammation and brain implica- 
tion. Neither must it be forgotten that more or less marked fever is often 
present, which may be attended with remissions, rigors, and sweats. 

Acute myelitis is a very grave disorder, and generally terminates fatally 
in the course of a few days or at the outside a few weeks. In the less 
severe or less extensive cases, however, life may be prolonged for an in- 
definite period with persistence of paraplegic symptoms ; or the patient 
may recover in some degree, or may even undergo perfect restoration to 
health. The cause of death varies. The patient frequently dies, however, 
of asthenia, which may be largely determined by secondary affections of the 
skin and urinary passages ; or of asphyxia referable to implication of the 
respiratory nerves. 

Treatment. — For the treatment of inflammation of the substance of the 
brain little or nothing can be done directly. We may, if the symptoms be 
severe and their onset sudden, have recourse to the classical measures : — 
namely, cold to the head in the form of evaporating lotions, affusion, or 
the ice-bag ; purgation by means of active drugs, and especially of such as 
cause watery evacuations ; and the abstraction of blood, preferably by 
leeches, from the temples or behind the ears, or by cupping at the nape of 
the neck. It must be admitted, however, that these measures are not 
often of any obvious utility. For the most part, however, the same general 
treatment may be employed here as has already been suggested for menin- 
gitis. If however, the affection be traceable to inflammation of the ear, 
or disease of the bones of other parts of the skull, the question of surgical 
interference will naturally arise. 

For the treatment of myelitis we must also refer to remarks which have 
been previously made under the head of spinal meningitis. 



V. SCLEROSIS. (Chronic Inflammation.) 

The affections which we are about to consider under the above heading 
form a very interesting clinical group, which has been mainly investigated 
and unravelled by the labors of Duchenne, Vulpian, and Charcot in France, 
by Todd, Gull, and Lockhart Clarke in our own country, by Brown- 
Sequard, and in a greater or less degree by various other physicians both 
here and abroad. They are probably all of inflammatory origin ; but the 
inflammation to the effects of which they are due is, like cirrhotic inflam- 
mation of the liver, marked, for the most part, by the slow development 



SCLEROSIS. 



883 



of adventitious fibroid tissue attended with the gradual wasting and de- 
generation of the essential elements. In some instances, according to 
Charcot, the inflammatory process begins in the nerve-cells, in which case 
it may either continue strictly limited to them, or gradually involve the 
surrounding connective tissue to a greater or less extent. 

In the majority of cases the first indication of disease would seem to 
consist in an overgrowth or hyperplasia of the neuroglia, indicated by the 
appearance in it, and in the perivascular spaces, of a greater or less abund- 
ance of the cells characteristic of embryonic tissue, together with an in- 
crease of the amorphous intercellular substance which takes part in the 
constitution of the neuroglia, and enlargement of the vessels. At this 
stage the affected tracts of tissue are somewhat swollen, but their nervous 
elements present little, if any, evidence of disease. As the morbid process 
advances, however, the hypertrophied neuroglia contracts and hardens, its 
newly-formed cells get small and indistinct, the originally amorphous 
matrix assumes a delicate fibrillated character, and the bloodvessels be- 
come thick-walled and their channels narrowed. Moreover, the nerve- 
tubules and nerve-cells of the diseased regions now undergo important 
changes. When the sclerosis is situated in the white substance of the 
cord or brain, the nerve-tubules are seen to be more widely separated from 
one another than natural, the width of the intervals between them depends 
ing of course on the quantity of adventitious matter which has accumulated 
there. The tubules for the most part diminish in thickness, mainly in 
consequence of the partial disappearance of the white substance of Schwann, 
and sometimes becomes moniliform; but, intermingled with such tubules, 
others may generally be observed which are either of normal thickness or 
are actually increased in diameter from swelling of the axis cylinder. In 
the most advanced conditions of disease the nerve-tubules are greatly 
atrophied, and in many instances wholly deprived of their myeline sheaths; 
but they are rarely, if ever, absolutely destroyed. When the sclerosis 
occupies the gray matter, as, for example, the anterior cornua of the cord, 
we find, in addition to atrophy of the nerve-tubules, corresponding changes 
in the nerve-cells. In some instances, as Charcot points out, they become 
swollen, and, it may be, enormously enlarged, faintly granular and opales- 
cent ; and at the same time their processes appear more or less thickened 
and twisted. These changes, which he ascribes to irritation, belong to the 
early period of the disease. Much more commonly the changes observed 
are of an atrophic character. In some cases the cells undergo pigmenta- 
tion, diminish in size, and assume a more or less globular form, their pro- 
cesses at the same time becoming attenuated and shortened ; and after 
awhile they get reduced to simple roundish accumulations of pigment, and 
finally perhaps wholly dissipated. In other cases no pigmental deposit 
takes place, but the cells shrink in all their dimensions, each one drying 
up, as it were, into a kind of mummy. The processes partake in this 
change, and disappear in a greater or less degree. Corpora amylacea are 
usually more or less abundant in sclerotic tracts ; and Lockhart Clarke has 
described as sometimes present in them irregular patches of disintegration, 
from which all traces of the normal elements of the part, whether neuroglia, 
bloodvessels, nerve-tubules, or nerve-cells, have disappeared. 

Sclerotic change is indicated, as to its coarser features, by a more or 
less grayish translucent aspect of the affected part, with induration, and, 
according to the length of time it has been in progress, either slight tume- 
faction, or a greater or less degree of contraction. Further, there is usually 



884 



DISEASES OF THE NERVOUS SYSTEM. 



close adhesion of the affected part to the pia mater over it, and more or 
less equivalent change in the pia mater itself. In most cases death occurs 
at an advanced period of the disease, and hence induration and diminution 
of bulk are generally observed. 

Sclerosis has a remarkable tendency to be limited in certain cases to 
definite tracts or regions of the nervous centres, and then comparatively 
rarely transgresses these limits. Thus certain cases (infantile and adult 
spinal paralysis, general spinal paralysis, and progressive muscular atrophy) 
are characterized by the limitation of the sclerosis to the anterior cornua 
of the gray matter of the cord, or more exactly (in many cases) to the 
groups of large nerve-cells therein situated — involving these parts, it may 
be, in their entire longitudinal extent, and rarely extending horizontally 
beyond them ; other cases (lateral sclerosis) are distinguished by the fact 
that the sclerotic change has its special seat in the lateral white columns, 
which are then usually symmetrically affected in a considerable part of 
their length ; other cases, again (locomotor ataxy) are peculiar in the fact 
that the sclerosis involves mainly and often exclusively the posterior white 
columns, or rather perhaps the outer bands of these columns, the fasciculi 
of Goll in many cases escaping ; while sometimes (glosso-labio-laryngeal 
palsy) the motor nuclei of the medulla oblongata are the special seat of 
disease; and at other times (disseminated sclerosis) the sclerotic change is 
scattered irregularly in patches throughout the nervous centres. 

A. Infantile Spinal Paralysis. (Infantile Paralysis.) 

Definition By these terms, as also by that of ' essential paralysis,' is 

known a peculiar paralytic affection coming on in young children, with 
acute symptoms, and for the most part with fever, and ending speedily 
in rapid atrophy of certain muscles or groups of muscles, and permanent 
paralysis. 

Causation — Infantile paralysis may, according to the statistics of M. 
Duchenne (fils), come on at any time from birth up to ten years of age. 
But the great majority of cases occur during the second year of life. Its 
causes are obscure ; it seems, however, neither to be hereditary nor to be 
dependent in any degree on privation or other conditions associated with 
poverty. Dentition would appear to be largely concerned in its causation, 
and it has often been observed to follow on measles, ' gastric fever,' and 
other febrile maladies. Exposure to cold and damp is undoubtedly a com- 
mon cause of the disease. 

Morbid anatomy The morbid processes of infantile paralysis concern 

the spinal cord, the motor nerves, and the organs of locomotion. In the 
spinal cord the only lesions which are usually observable occupy the ante- 
rior cornua. They consist mainly in pigmental degeneration and atrophy 
of the groups of large cells, which tend ultimately to disappear completely. 
Herewith, however, is usually associated more or less sclerotic change in 
the tissues in which these cells are imbedded. The affection is obviously in- 
flammatory, and, although commonly involving the neuroglia as well as the 
nerve-cells, is sometimes limited to the cells, or to these and the portions 
of neuroglia immediately surrounding each. Whence Charcot regards the 
inflammatory process as commencing in the nerve-cells, and as implicating 
the neuroglia secondarily only. The morbid process affects the various 
regions of the anterior cornua indifferently, and by no means necessarily 
symmetrically ; it may involve them in patches, or uniformly throughout 



J 



INFANTILE SPINAL PARALYSIS. 



885 



a considerable vertical extent. The diseased cornua ultimately shrink in 
proportion to the degree and duration of the morbid process. 

The motor nerves are involved secondarily to the spinal cord, and only 
at a comparatively late period of the disease. They undergo atrophy, the 
ultimate tubules diminishing in size and tending to lose the myeline 
sheaths. The muscles which are implicated in the disease shrink rapidly. 
In the first instance the only obvious and constant change is a diminution 
in the diameter of the fibres, with some hyperplasia of the cells of the 
sarcolemma, and, according to some observers, more or less overgrowth of 
the intervening connective tissue. But even in the early stage a few 
muscular fibres will often be found to have lost their transverse striation 
and to have become granular. At a late period of the disease the atrophy 
of the fibres has become more complete, and they then not unfrequently, 
but by no means necessarily, present well-marked fatty degeneration. At 
this time, also, there is often more or less increase of intervening con- 
nective tissue, and sometimes a large accumulation of fat. The conse- 
quences, as regards the general form and bulk of the muscles, are various: 
in some cases they appear simply shrunk to an extreme degree; in other 
cases they are found to retain more or less of their normal size and shape; 
and occasionally they present a positive increase of bulk, owing to the 
accumulation between their fibres of adipose or fibrous tissue. 

Symptoms and progress The onset of infantile paralysis is usually 

sudden, and marked by more or less intense fever, occasionally attended 
with convulsions, coma, or other cerebral symptoms. The duration of this 
febrile attack, which, however, is not always present, varies from a few 
hours to a couple of weeks. The paralytic condition of the muscles for 
the most part comes on quickly and unexpectedly. Sometimes the child 
is found paralyzed on waking up from sleep ; sometimes on the subsidence 
of coma or convulsions, or on the disappearance of some specific fever or 
of the special fever of the disease, or in the course of that fever. The 
paralysis increases rapidly from the moment of its first appearance, so that 
at the end of a day or two, sometimes however after a longer interval, it 
has attained its maximum degree and extent. Its extent varies of course 
in different cases: sometimes both arms and legs are uniformly and com- 
pletely paralyzed ; sometimes the legs only ; sometimes the arms only ; 
sometimes a single extremity ; and sometimes, and on the whole more 
commonly, groups of muscles belonging to one limb or to several limbs. 
The paralysis is marked from the first by flaccidity of the muscles, and 
abolition or impairment of reflex excitability. Moreover (and this is a 
point of capital importance), great diminution or absolute abolition of 
electrical contractility rapidly supervenes in the affected muscles, so that 
at the end of five days, or it may be a week, many of the muscles may 
have entirely ceased to contract under the influence of faradism. Occa- 
sionally pain in the back and pain on movement of the limbs would appear 
to attend the commencement of* the disease, but these phenomena form no 
essential feature of its clinical history, and certainly in a large number of 
cases are wholly wanting. According to Dr. West, more or less cutaneous 
hyperesthesia is present at this time, and may continue for several weeks; 
but this is far from being a constant phenomenon. Indeed, it may be 
regarded as characteristic of the disease that absolute paralysis of certain 
muscles, attended with flaccidity and loss of reflex and faraclic contractility, 
is linked with an almost total absence of pain, retention of cutaneous sen- 
sibility, perfect control over the rectum and the bladder, and an entire 



886 



DISEASES OF THE NERVOUS SYSTEM. 



lack of all tendency to inflammation of the urinary organs, formation of 
bed-sores, or appearance of cutaneous eruptions. The first stage of the 
disease characterized by the phenomena which have just been enumerated 
lasts from two to six months — sometimes, however, a longer, sometimes 
a shorter time — and is then followed by the second stage, which continues 
probably for another six months. During this stage more or less amend- 
ment generally takes place ; certain of the paralyzed muscles, and more 
especially those in which faradic contractility had not been wholly abolished, 
slowly regain their normal reflex and electrical properties and their power 
of spontaneous movement ; a greater or lesser number, however, of the 
muscles which had lost their faradic contractility probably remain (singly 
or in groups, or occupying the whole of one or more limbs) permanently 
paralyzed ; and not only remain paralyzed, but undergo more or less rapid 
atrophy. Any improvement, excepting in those muscles which are already 
in progress of amendment, can scarcely be hoped for after the lapse of eight 
or ten months from the commencement of the disease. 

The changes which now slowly ensue are interesting. In the first place 
the permanently paralyzed muscles, which had already perhaps given indi- 
cations of shrinking at the end of a month from the beginning of the dis- 
ease, become rapidly atrophied — generally undergoing much reduction in 
size, but sometimes retaining more or less of their natural bulk in conse- 
quence of overgrowth of interstitial connective tissue and fat. They con- 
tinue perfectly limp, and wholly impassive under the influence of every 
kind of stimulus. In the second place, it often happens that the bones of 
the affected members become arrested in their development, and are con- 
sequently at the time of full growth thinner and shorter, sometimes con- 
siderably shorter, than they should be. This result has been observed 
several times by Volkmann in cases in which the primary disease was of 
short duration, and paralysis had wholly disappeared. In the third place 
the paralyzed limbs show a striking and permanent diminution of tempera- 
ture, a diminution which is more marked than in any other form of paral- 
ysis. It appears to be connected with a general diminution in the bore of 
the bloodvessels. In the fourth place, various deformities, mainly of the 
hand and foot, are apt to ensue. These generally begin to show themselves 
about the end of 'the first year, and depend apparently on the unequal de- 
grees in which opposing muscles are affected, and on the predominant action 
therefore of the healthy or less completely paralyzed muscles. Their pro- 
duction is largely aided by the remarkable laxity of the ligaments, which 
is also usually present in these cases. The most common deformity of the 
foot is talipes equinus. 

Cases of infantile paralysis occasionally depart from the type above 
sketched. Sometimes the disease lasts for a few days or a few weeks 
only, and complete restoration to health ensues ; sometimes the paralysis, 
instead of being developed with sudden intensity, creeps on gradually, 
and attains its full development only after some length of time ; some- 
times, again, the patient suffers from occasional exacerbations or relapses. 

Treatment — In the early stage of infantile paralysis, treatment must be 
mainly expectant. Salines, laxatives, and other febrifuge medicines may 
be used with some advantage, and in some cases perhaps counter-irritation, 
or the abstraction of blood by leeches or cupping-glasses applied in the 
course of the spine. The patient should, of course be kept absolutely at 
rest, and careful attention should be bestowed in order to relieve symptoms 
and obviate the occurrence of complications. Bat, after all febrile symp- 



ADULT SPINAL PARALYSIS. 



887 



toms have passed away, and all acute inflammatory mischief has subsided, 
which will probably be at the end of three or four weeks, it will be neces- 
sary to adopt measures to promote the restoration of those muscles which 
are capable of restoration. The affected muscles may be divided into 
three categories: first, those which, though paralyzed, have their faradic 
contractility but slightly affected ; second, those in which the faradic con- 
tractility is much enfeebled or abolished, but which respond to galvanism ; 
and, third, those which fail to react to any form of electricity. Muscles 
belonging to the first category tend to recover completely, independently 
of all treatment ; but nevertheless the periodical application of faradism or 
galvanism to them tends to hasten their recovery. Muscles belonging to 
the second category for the most part undergo more or less considerable 
atrophy, which may continue to progress for many months, and may result 
in their permanent emaciation and weakness, even though complete resto- 
ration of the nerves and nerve-centres in relation with them ultimately 
takes place. In these cases the long-continued and systematic use of 
galvanism, especially if it be commenced early, will often serve to arrest 
the wasting of the muscles, and ultimately to bring them back to the con- 
dition of health. The prospects as regards the muscles in the third class 
are much more gloomy. They invariably waste rapidly, and in a very 
large proportion of cases fail absolutely to undergo any kind of improve- 
ment. Still, even here, the solicitous and long-continued use of galvanism 
sometimes succeeds in effecting a more or less important improvement. It 
need scarcely be said that the longer recourse to electric treatment is de- 
layed, the less is the chance which it affords of benefit. Nevertheless, a 
case recorded by Duchenne, in which the complete restoration of many 
muscles of the arm (which had been atrophied and had lost all electric 
contractility for a period of four years) was effected by means of faradism 
applied periodically during the space of two years, proves that we need 
not despair even when circumstances seem most adverse. An important 
result to be derived from electricity, even when it fails to cure absolutely, 
is the prevention of the deformities due to the unequal action of antago- 
nistic muscles. In conjunction with electricity, other measures may be 
used to improve the condition of the muscles ; among which may be enu- 
merated exercise, rubbing, shampooing, baths, and mechanical measures 
to obviate the tendency of certain muscles to contract and cause deformity. 
Iron and other tonics are, in a certain sense, useful. Strychnia has been 
largely recommended. [This may be injected under the skin in the neigh- 
borhood of the paralyzed muscles with great advantage. Bar well has used 
a very strong solution for this purpose, and, he asserts, without the pro- 
duction of any symptoms of poisoning.] 

The treatment of the results of infantile paralysis belongs to the 
surgeon. 

B. Adult Spinal Paralysis. 

Both Duchenne and Charcot have published cases (and, indeed, it 
seems probable that such cases are not uncommon) in which adults have 
been attacked with disease resembling in all essential particulars infantile 
paralysis. The recorded cases show : that it comes on in adults, as in 
children, with more or less severe febrile symptoms, lasting, it may be, 
for a few days, and attended with or followed by motor paralysis of a 
greater or lesser number of voluntary muscles, but without implication of 



888 



DISEASES OF THE NERVOUS SYSTEM. 



cutaneous sensibility, loss of control over the rectum or bladder, or tend- 
ency to the formation of bed-sores ; that the muscles are flaccid, incapable 
of excito-motor action, and tend rapidly to lose their faradic contractility, 
and to waste ; and that, after the paralysis has reached its highest degree, 
more or less amendment takes place in some of the muscles. It not un- 
commonly happens in the case of the adult, as probably happens also in 
the child, that pain in the spine, with forward curvature, and some degree 
of pain in the limbs, attend the onset of the disease. The chief point in 
which the history of the disease in adults differs from that of the disease 
in children is the necessary absence from it of all mention of the various 
deformities resulting from defective development ; the bones do not be- 
come relatively short ; and deformities connected with the joints are less 
extreme. 

The pathology and treatment are the same as in the infantile disorder. 

C. General Spinal Paralysis. 

Definition The malady referred to under the above name is in the 

third edition of Duchenne's treatise 'De l'P^lectrisation Localisee,' entitled 
6 paralysie generale spinale anterieure subaigue.' It is characterized by 
more or less general paralysis with wasting and flaccidity of the muscles, 
and marked loss of electrical contractility, unattended with implication of 
the rectum or bladder, or with brain symptoms, and tending in many cases 
to end in recovery. 

Causation. — The causes of this affection are not known. It has been 
referred to exposure to cold and wet. There is no reason to regard it as 
hereditary. It comes on mainly between the ages of thirty-five and 
forty. 

Morbid anatomy. — The anatomical lesion which underlies the phe- 
nomena by which the presence of general spinal paralysis is revealed has 
not yet been ascertained ; but there is reason to believe that the disease 
resembles acute spinal paralysis of children and of the adult in the facts, 
that the parts which are specially implicated are the anterior cornua of 
the gray matter of the cord, and that the lesion is inflammatory. 

Symptoms and progress. — The paralytic phenomena may begin in the 
upper extremities, and, thence travelling downwards, gradually become 
general; or they may take their origin in the legs, and thence extend 
upwards to the rest of the body. The latter course is by far the most com- 
mon. In that case the patient first experiences weakness in one or both 
lower extremities — if in both, with predominance in one of them. Should 
a careful examination be made at this time, it will probably be found 
that the flexors of the foot on the leg suffer first and most severely, 
then those of the thigh on the trunk, and subsequently the extensors 
of the leg upon the thigh. The paralysis increases progressively until the 
patient can neither stand nor walk, and ultimately his limbs become en- 
tirely motionless. No trembling, no convulsive movements, no inco-ordi- 
nation, no rigidity or contraction attends the progress of the disorder. 
The affected muscles are, however, flaccid from the beginning, and very 
rapidly, though somewhat irregularly, lose their faradic contractility, until 
at length, as sometimes happens, it ceases totally. Very soon, also, the 
paralyzed muscles waste — the atrophy not affecting single muscles, as in 
progressive muscular atrophy, but involving all the paralyzed muscles 
coetaneously, so that the limbs shrink in their whole extent, and acquire 



PROGRESSIVE MUSCULAR ATROPHY. 



889 



a resemblance to those of a mummy. The surface, at the same time, is 
apt to get cold and livid. The paralysis remains limited, for a longer or 
shorter time, to the lower extremities. Jn some cases, the hands begin to 
lose power ere the affection of the lower limbs is five or six weeks old. 
In other cases, the upper extremities are not involved until after the lapse 
of several months or years. But when once the paralysis has reached 
them, it pervades them progressively and rapidly, first attacking the ex- 
tensors of the fingers, and then taking much the same course that it pre- 
viously took in the lower extremities. Subsequently, the muscles of the 
trunk and of the head and neck become implicated. Generally, the paral- 
ysis is more marked on one side of the body than the other. If the paral- 
ysis be not arrested in its course, or do not undergo amendment, it extends 
at length to the muscles supplied by the nerves of the medulla oblongata ; 
whence result difficulty of articulation, difficulty of deglutition, and respi- 
ratory trouble. 

The progress of the disease may be uniform and continuous, or it may 
be interrupted from time to time by long intervals, during which the symp- 
toms remain in abeyance or undergo more or less obvious amendment. 
Sometimes the patient recovers completely, only to have a relapse at some 
subsequent period. Not unfrequently patients succumb, especially under 
the effects of implication of the medulla oblongata, or from syncope. On 
the other hand, many persons recover absolutely, even after they have suf- 
fered from the disease for some months or years, and even after the wast- 
ing of the limbs and the loss of faradic contractility have persisted for a 
considerable period. The duration of the disease varies from a few months 
to many years. 

Among the more striking characteristics of general spinal paralysis are: 
its insidious origin, unattended with febrile or other symptoms ; its pro- 
gressive invasion of all the voluntary muscles, and the rapid loss of their 
faradic contractility and bulk; the wasting of the limbs in mass, and not 
muscle by muscle; the absence of all paralytic tremblings and convulsive 
movements ; the retention of cutaneous sensibility, of control over the 
emunctories, and of the mental faculties ; and the tendency which is mani- 
fested to ultimate recovery. 

Treatment In treating cases of general spinal paralysis, it must always 

be remembered that many cases ultimately do well quite irrespective of 
medical treatment. There is, indeed, but little to be done medicinally. 
The usual round of drugs which are employed in nervous disorders may 
be tried. With more hope of benefit, faradism or galvanism, periodically 
and persistently administered, may be had recourse to for the treatment of 
the paralyzed muscles. 

D. Progressive Muscular Atrophy. ( Wasting Palsy.) 

Definition. — This disease is characterized by progressive atrophy com- 
mencing in certain muscles, usually those of one hand, next involving, as 
a rule, corresponding muscles on the opposite side of the body, and grad- 
ually spreading to other muscles of the limbs and trunk. 

Causation. — Progressive muscular atrophy occurs both in children and 
in adults, and principally in males. Its causes are obscure. It has 
been traced apparently to exposure, to excessive bodily or mental exer- 
tion, and to violent emotions ; but mainly it appears to be an hereditary 



890 



DISEASES OF THE NERVOUS SYSTEM. 



affection. In almost all cases of its occurrence in children, whi°h have 
come under Duchenne's ob jrvation, it appears to have been her' litary. 

Morbid anatomy — The pathology of this affection differs little from 
that of infantile spinal paralysis. The parts affected are, in this case, as 
in that, the anterior cornua, the motor nerves which emerge from them, 
and the muscles which these nerves supply. The affection is limited in 
many cases to certain groups of large cells — the cells undergoing the vari- 
ous forms of degeneration which have already been described, and finally, 
it may be, disappearing altogether ; or it may include with these changes 
a greater or less amount of sclerosis of the contiguous portions of the 
anterior cornua, and corresponding atrophy of the nerve-tubules. In the 
early stage, the bloodvessels of the affected parts are enlarged and their 
walls + T ^'ckened. The anterior nerve-roots, which are connected, on the 
one l % with the diseased portions of cord, on the other with the affected 
muscles, undergo similar changes to those which have been described in 
connection with infantile paralysis ; but the degeneration is never so ex- 
treme or general, nor does it distinctly manifest its presence until the 
muscular atrophy has made considerable progress. The muscular change 
consists essentially in a mere attenuation of the muscular fibres with more 
or less proliferation, of an abortive character, of the cells of the sarcolemma. 
Granular and fatty degeneration, with disappearance of the transverse striae 
may supervene at a late period of the disease ; but it is merely a secondary 
phenomenon, and has no special significance. Hypertrophy of the con- 
nective tissue investing the muscular fibres, and accumulation of fatty 
matter in the same situation are not uncommon. The affection of the nerve- 
centres is distinctly inflammatory, and precedes and causes the lesions of 
the motor nerves and muscles. 

Symptoms and progress — Progressive muscular atrophy, unlike acute 
spinal paralysis, comes on insidiously. Its advent is unattended with fever 
or other obvious constitutional disturbance. Indeed, the first indication 
of its presence is, almost without exception, wasting and loss of power of 
some muscle or group of muscles. The muscular atrophy may commence 
at any part, but most commonly commences in the hand, especially the 
right hand, whence it spreads first to the corresponding muscles of the 
opposite side of the body, then to those of both forearms, and presently be- 
comes distributed with more or less irregularity, but symmetrically, 
throughout the trunk and lower extremities. 

When it takes the orthodox course, it is the muscles of the ball of the 
right thumb which are usually first affected. Then the muscles of the 
hypothenar eminence and the interossei suffer ; and the hand acquires an 
almost pathognomonic claw-like form. Next the muscles of the forearm 
waste, with some irregularity as to the order of their wasting. Subse- 
quently the muscles of the upper arm and shoulder suffer, the triceps for 
the most part retaining its normal condition longer than the others. The 
muscles of the trunk usually suffer coetaneously with those of the upper 
arm, but are involved irregularly. The usual order, however, of their in- 
volvement is, according to Duchenne: first, the trapezius (of which the 
lower portion suffers earliest) ; then successively the pectorals, the latissi- 
mus dorsi, the rhomboidei, the levator anguli scapulae, the extensors and 
flexors of the head, the sacro-lumbalis, and the abdominal muscles. When 
the atrophy has extended thus far, the muscles of respiration and degluti- 
tion usually become affected. The clavicular portion of the trapezius is 
the last of the muscles of the trunk to succumb. The lower extremities 



PROGRESSIVE 



MUSCULAR 



ATROPHY. 



891 



are involved subsequently to the arms and trunk, but their muscles are 
apt to s ^er equally in degree with those of Mother parts. The muscles 
which are earliest affected are the flexors of the foot on the leg, and those 
of the thigh upon the pelvis. 

Not unfrequently progressive muscular atrophy first shows itself among 
the muscles of the trunk, attacking sometimes the pectorals, sometimes the 
serratus magnus, sometimes the spinal muscles, sometimes those of the 
abdomen, and thence extending to the other trunk-muscles and to those of 
the extremities. Its commencement in the lower extremities is exceed- 
ingly rare. 

A curious circumstance is pointed out by Duehenne, namely, that when 
progressive muscular atrophy attacks young children, its invasion is marked 
by the effiicement of some of the muscles of expression ; that the'-' aspect 
consequently becomes more or less idiotic ; that their cheeks becv>l rl dac- 
cid and their lips large and pendulous ; and further, that it is only subse- 
quently, and it may be after the lapse of years, that the muscles of the 
trunk and those of the limbs partake in the atrophic change. 

In addition to the fact that progressive muscular atrophy is a disease of 
an essentially chronic character, and tends from insignificant beginnings 
slowly to involve a large number of the voluntary muscles of the limbs 
and trunk, it presents several other remarkable features which help to dis- 
tinguish it from acute spinal paralysis and from other spinal disorders to 
which in many respects it has a more or less close resemblance. First, 
the enfeeblement of the affected muscles does not precede the atrophy ; it 
follows upon the atrophy, is due to it, and is proportional to it; and indeed 
the motor power is not wholly lost until a very late stage of the disease, or 
until the muscles have undergone complete atrophy. Second, the faradic 
contractility of the affected muscles remains unimpaired, or rather dimin- 
ishes only in proportion to the effacement of the constituent muscular 
fibres, and never disappears absolutely until voluntary power is wholly 
lost, namely, when atrophy has reached its extreme degree. Third, a 
very common feature of the malady is the presence in the affected muscles 
of irregular vibratile movements of the individual fibres, which may be 
seen and felt, and which, when superficial muscles are under observation, 
give to the eye an appearance as though innumerable slender worms were 
in active parallel progression under the skin. These fibrillar oscillations 
are occasionally so violent as to cause movements of flexion and extension 
in the fingers or other parts. They are not constant, and are usually 
evoked either by the patient's effort to bring the muscles into action, or 
by tapping, pinching, or otherwise exciting them. They are not peculiar 
to progressive atrophy, although they commonly attend it. 

Characters which are common to this affection and to spinal paralysis 
are a lowering of the temperature of the affected limbs, absence of spinal 
or neuralgic pain and of tendency to the formation of bed-sores or to the 
appearance of cutaneous eruptions, and retention of control over the emunc- 
tories. Cutaneous sensibility is generally retained. It is well to bear in 
mind that the wasting of muscles is often concealed by the presence of an 
excess of subcutaneous fat, and that hence the true condition of things can 
often be determined only after careful investigation. 

The course of progressive muscular atrophy is always slow and irregu- 
lar. It may appear in some of the muscles of the face or hand, and years 
may elapse before it extends either to neighboring muscles or to the cor- 
responding muscles of the opposite sides of the body. Or it may invade 



892 



DISEASES OF THE NERVOUS SYSTEM. 



the muscles of the arms or legs with comparatively great rapidity, and 
then a long interval of quiescence may ensue. It may even become ar- 
rested in its onward progress never to be reawakened. Most commonly, 
however, it advances either uniformly or by fits and starts, until the patient 
becomes utterly helpless. The duration of the affection is very various. 
In many cases the patient survives for eight or ten years, or even for twice 
that period. And, indeed, there is nothing to interfere with the duration 
of life unless the muscles of respiration or those of deglutition get involved. 
If this happen, the patient is liable to be cut off either by inability to 
swallow, by choking, or by difficulty of breathing, and the pulmonary 
complications which are then so apt to ensue. If these important parts are 
early implicated, the patient may succumb within two or three years from 
the commencement of his malady. 

Treatment The treatment of progressive muscular atrophy calls for 

no special observation. It may be the same that has been recommended 
for the chronic stages of acute spinal paralysis, and especially the sys- 
tematic use of electricity to the affected muscles. M. Duchenne, who 
strongly urges the beneficial influence of this treatment, says that the pro- 
gress of the disorder may sometimes be arrested, and muscles not too far 
advanced in atrophy may occasionally be restored by it. He prefers fara- 
dism applied in turn to each affected muscle, but recommends also the 
concurrent use of the direct current — constant or interrupted. He specially 
advocates the solicitous treatment of those muscles which are the most 
important either for the maintenance of life or the usefulness of the limbs. 
The following are some of the rules which he lays down. The more a 
muscle is atrophied, its contractility diminished, and its sensibility be- 
numbed, the longer it should be subjected to stimulation, the more intense 
should be the current and the more rapid its intermissions. But when 
sensibility returns it is prudent to diminish the intermissions, and abate 
the intensity of the current, and even to abridge the number of sittings, 
lest unmanageable neuralgia be provoked. No sitting should be prolonged 
beyond ten or fifteen minutes, and rarely more than one minute should be 
given to each muscle. 

E. Lateral Sclerosis. 

Definition The affections which it is intended to comprise under the 

above designation are those to which JM. Charcot applies the names of 
' amyotrophies spinales deuteropathiques,' and ' sclerose laterale amyotro- 
phique.' They are essentially characterized : first, as regards their mor- 
bid anatomy, by a sclerotic change affecting the lateral white columns of 
the cord symmetrically and in their whole length, and in the majority of 
cases extending thence so as to involve more or less of the anterior cornua, 
and occasionally of the sensory elements ; second, as regards their clinical 
phenomena, by paralysis of the limbs with rigidity and tendency to con- 
tract, associated with more or less wasting of muscles and sometimes with 
neuralgic pains. 

Causation. — The causes of the inflammatory process which induces 
sclerosis in the lateral columns are various. This lesion is a common con- 
sequence of effusion of blood into the substance of the cerebrum, or of the 
presence of a patch of softening, and equally follows any destructive lesion 
of the crura, pons, medulla oblongata, or spinal cord. It is occasionally 
of idiopathic origin, under which circumstances, according to Charcot, it 



LATERAL SCLEROSIS. 



893 



does not appear to be hereditary, seems to occur more frequently in women 
than men, and mainly between the ages of twenty-six and fifty. Some 
patients refer the disease to the influence of cold and wet, and some to 
injury. 

Morbid anatomy The simplest form of lateral sclerosis, both patho- 
logically and clinically, is that which occurs secondarily to some cerebral 
or other lesion. We have already drawn attention to the fact of its occur- 
j rence under the conditions here specified. In old cases of cerebral hemor- 
\ rhage or softening, a tract of sclerosis, the upward limit of which has not 
yet been determined, may often be traced along the crusta of the corres- 
| ponding crus cerebri, through the pons, into the anterior pyramid, which 
may be involved in pretty nearly its whole horizontal and vertical extent, 
j and along the decussation to the opposite sMe of the cord, in which it 
occupies almost exclusively the lateral white column, being separated, 
| however, from the surface by a persistent lamina of still healthy white 
j matter. In the neck the sclerotic change may extend from the outer angle 
of the anterior cornu in front to the posterior nerve-root behind. But in 
its passage down the cord it occupies a smaller and smaller space, both rel- 
j atively and actually, and at the same time limits itself more and more to 
the neighborhood of the posterior cornu and the nerve-fibres springing 
' from it. Thus in the middle of the dorsal region its anterior limit corres- 
ponds to a transverse line drawn through the commissure, while in the 
lumbar enlargement it occupies only the posterior fourth of the lateral 
column. Occasionally the fasciculi of Turek (narrow tracts of white 
matter situated on either side of the anterior median fissure, and belong- 
ing apparently to the same system as the lateral columns) share in the 
| morbid change. It is very rare, however, for any other part to be im- 
plicated. 

Lateral sclerosis of idiopathic origin affects identically the same tracts, 
but in this case both sides of the cord are as a rule simultaneously impli- 
cated, and the morbid process presents a symmetrical character. Another 
important distinction between the secondary and idiopathic forms of the 
lesion is afforded by the fact that in the former the morbid process rarely 
extends horizontally beyond the lateral white columns, while in the latter 
such extension constitutes the rule. When lateral extension takes place, 
it is seldom if ever general ; it comparatively rarely involves the sensory 
tracts of the gray matter of the cord, the posterior columns, or the posterior 
roots ; but almost always it is the anterior cornua with their groups of 
large cells which suffer. The anatomical lesion, in fact, which constitutes 
the basis of the group of affections last considered, becomes superadded 
to the primary lesion of the lateral columns. This lateral extension, how- 
ever, does not occur in all situations equally, nor does it take place here 
and there indifferently. It is almost invariably most advanced in the cer- 
vical portion of the cord, and diminishes gradually thence downwards. It 
comes on also, though at a comparatively late period of the disease, in the 
medulla oblongata, leading then to special implication of the nuclei of the 
spinal accessory, hypoglossal, vagus, and facial nerves. Both the naked- 
eye and the microscopic characters of sclerosis have already been suffi- 
ciently considered. It need only be added that the sclerotic process in the 
anterior cornua, which is associated with lateral sclerosis, is undistinguish- 
able from that which occurs primarily in them ; and that it is followed 
sooner or later by the same secondary changes in the motor nerves and 



894 



DISEASES OF THE NERVOUS SYSTEM. 



voluntary muscles which have already been described in connection with 
infantile paralysis. 

Symptoms and progress.— The symptoms specially referable to disease 
of the- lateral columns are gradually developing paralysis of the muscles 
with which the affected tracts are in relation, attended with more or less 
violent tremors during the attempt to perform voluntary movements, and 
gradually increasing rigidity, often coming on in paroxysms, and easily in- 
duced by any kind of irritation. The rigidity is at first general, and in- 
duces extension of the limbs ; but subsequently the flexors tend to over- 
power the extensors, and the limbs become more or less strongly flexed. 
Besides the sudden spasmodic contractions just referred to, the paralyzed 
muscles are liable to more or less prolonged paroxysms of convulsive 
trembling. The affected muscles do not waste, and they retain their faradic 
contractility and reflex excitability unimpaired. Nor is there loss of sen- 
sation or pain. 

These phenomena are often observed in the lower extremities of persons 
who are paraplegic from pressure, or disease involving a limited length of 
the cord, and are then referable to the descending lesion of the lateral 
columns which is so apt to ensue under these circumstances. Rigidity and 
contraction, due to the same cause, are also of common occurrence in the 
paralyzed limbs in cases of old cerebral mischief. In idiopathic sclerosis, 
however, of the lateral columns, the extension of disease horizontally into 
other regions of the cord necessitates the superaddition of other symptoms 
to those which have just been enumerated ; these are, occasionally more 
or less pain, numbness or tingling from implication of the posterior roots 
or posterior horns, but especially more or less rapid wasting of some of the 
paralyzed muscles from involvement of the anterior cornua. The phe- 
nomena of the idiopathic affection are, of course, largely dependent, as 
regards their gravity and distribution, on the longitudinal extent to which 
the lateral columns are implicated, and on the destination of the motor 
nerves whose nuclei suffer from its horizontal extension. 

In most cases the idiopathic disease comes on insidiously, without fever 
or premonitory symptoms other than perhaps some numbness or tingling 
in the limb over which paralysis impends. The arms are usually first im- 
plicated, first one, probably, and the other after a short interval. They 
become enfeebled and more or less emaciated ; the enfeeblement, however, 
precedes the emaciation, or goes along with it, and does not, as in wasting 
palsy, follow it. Moreover, in lateral sclerosis, the paralysis and wasting 
affect all the muscles of the affected limbs simultaneously instead of, as in 
the other case, creeping from muscle to muscle. Further, the shrinking 
muscles are liable, as are those of wasting palsy, to fibrillar vibrations, and 
retain like them their faradic contractility ; and, moreover, so long as any 
voluntary motor power remains in them, their movements are generally 
attended with more or less violent trembling. But, in addition to the phe- 
nomena above enumerated, the emaciated and paralyzed limbs soon become 
rigid and contracted, and, as a consequence of this contraction, deformed. 
Each arm is kept closely applied along the side of the body, and the 
shoulder resists when we attempt to abduct it; the forearm is semiflexed 
and pronated, and cannot be extended or supinated without the use of con- 
siderable force, and exciting pain ; the hand is flexed on the forearm ; and 
the fingers also are flexed. In the further progress of the case emaciation 
tends to become extreme ; and at length with the atrophy of the muscles 
their capability of contracting under the stimulus of electricity may fail, 



LATERAL SCLEROSIS. 



895 



and their rigidity and contraction may to some extent disappear. In some 
1 cases the muscles of the neck get rigid, like those of the arms, and the 
patient has pain and difficulty in moving his head. 

The atrophy of the arms in this affection is far more rapid than in pro- 
I gressive muscular atrophy, mainly, no doubt, because all the muscles are 
involved at one and the same time ; and at the end of four, five, or six 
| months, or at the outside a year, the emaciation is as extreme as we observe 
it to be in cases of progressive muscular atrophy which have been in pro- 
! gress for several years. From six months to a year or more after the 
I commencement of the disease, the lower extremities generally first give 
signs of involvement. The patient complains of numbness, tingling, and 
! loss of power in them ; but in their case there is very seldom any atrophy, 
I owing evidently to the fact that the motor nuclei of the dorsal and lumbar 
regions are scarcely ever involved. The paralysis of the legs, however, 
i makes rapid progress ; the patient soon cannot walk without being sup- 
ported on both sides ; and before long all voluntary movement ceases in 
I them. Long ere the paralysis is complete the legs are liable to spasmodic 
! contractions, which come on without obvious cause, and are readily excited 
; by any form of stimulus ; they become suddenly rigid, sometimes flexed, 
I sometimes extended, and are apt to remain for some time in that condition, 
j These spasms are chiefly liable to occur when he attempts to walk, and 
then especially cause powerful adduction of the thighs, with more or less 
marked extension at the different joints. [This is, of course, nothing more 
than a form of the " clonus," which was fully described in the introductory 
remarks to this chapter. In no disease is it more marked than in this. 
The tendon reflexes are also exaggerated.] The extension at the ankle- 
joints imparts to the feet the attitude of talipes equino-varus. Associated with 
the spasms are more or less violent tremblings, which add to the patient's 
difficulty of walking. When the paralysis is complete, the rigidity be- 
comes permanent, the legs being in some cases extended, in some flexed, 
and exceedingly difficult to bend or straighten. At this time prolonged 
paroxysms of spasmodic trembling can often be readily induced. After a 
while, but this is a remote and comparatively rare event, the muscles of 
the legs may undergo atrophy like those of the arms ; and with the advance 
of this atrophy the rigidity gradually relaxes. There is no paralysis of 
bladder or rectum, or tendency to the formation of bed-sores. 

While the legs are becoming paralytic, or it may be after arms and 
legs have lost all power of voluntary movement, another series of phe- 
nomena gradually supervenes, referable to implication of the motor nuclei 
of the medulla oblongata. These are : paralysis of the lips and face ; 
paralysis of the tongue ; paralysis of the soft palate ; and paralysis of the 
parts to which the vagus is distributed — a group of phenomena which will 
hereafter be considered as a distinct affection, under the name of ' glosso- 
labio-laryngeal palsy.' 

The progress of idiopathic lateral sclerosis is not always in accordance 
with the above sketch. Sometimes it commences in the lower extremities, 
! sometimes it is limited to one arm or leg, or assumes a hemiplegic form, 
j and rarely it first reveals itself by implication of the nerves of the medulla 
| oblongata. 

The prognosis of the disease, at all events when it presents distinctive 
! characters, is exceedingly gloomy. Its various stages follow one another 
i surely and rapidly, and death usually takes place within one, two, or 
I three years from the commencement of paralytic symptoms. The contrast 



! 



896 



DISEASES OF THE NERVOUS SYSTEM. 



in this respect between lateral sclerosis and wasting palsy is very striking. 
Death is generally due to accidents connected with involvement of the 
nerves of the medulla oblongata. 

Treatment It is needless to endeavor to lay down rules for the treat- 
ment of this disease. All that can be done is to attend to the general 
health, to resort to electricity, friction, and such-like measures, and to 
obviate as far as possible the various discomforts and dangers to which 
the patient is exposed. 

F. Tabes Dorsalis. (Locomotor Ataxy.) 

Definition By the above terms is understood a peculiar affection 

characterized : anatomically by sclerosis of the posterior columns of the 
cord ; clinically by loss of co-ordinating power in the lower extremities, 
gradually increasing in degree and extent, and generally sooner or later 
involving the upper extremities and other parts. Various nervous lesions, 
which need not now be specified, are frequently associated with the mus- 
cular inco-ordination. 

Causation The causes of locomotor ataxy, like those of most other 

affections of which a sclerotic condition of the nervous centres forms the 
anatomical basis, are exceedingly obscure. The disease has been referred 
by some to sexual excesses, by some to exposure to cold and wet, by some 
to over-exertion, injury, or shock. But little more can be said positively 
than that in many cases some one of these various conditions has preceded 
the occurrence of the nervous phenomena. In the greater number of cases, 
however, no cause whatever can be assigned. The disease is occasionally 
hereditary, or runs in families, and, further, seems not unfrequently to be 
associated in families with insanity, epilepsy, and other affections of the 
nervous system. It seldom occurs in women ; and generally first makes 
its appearance between the ages of twenty and forty-five. It sometimes, 
however, comes on at an advanced period of life, and sometimes about the 
age of puberty. 

Morbid anatomy. — The specific lesion of locomotor ataxy is sclerosis 
of the posterior columns of the cord ; both columns, as a rule, being 
equally affected, and the morbid change being most advanced in the lower 
part and diminishing from below upwards. In many cases the posterior 
columns are involved in their whole horizontal extent. Bat it is shown 
by Charcot that such an amount of disorganization is unnecessary for the 
production of the characteristic symptoms of the disease ; that in some 
cases the posterior median columns or fasciculi of Goll remain perfectly 
healthy ; and that, in fact, the tracts whose lesions induce ataxic symp- 
toms are two narrow bands of white matter, lying, one on each side, be- 
tween the inner and posterior aspect of the posterior cornu and nerve-roots 
on the one hand, and the posterior median column on the other. The 
sclerotic change occurring in these parts calls for no specific naked-eye or 
microscopic description ; the affected columns become indurated, gray, 
and translucent, in the early stage a little swollen, but at a later period 
notably diminished in bulk. The disease, however, rarely remains strictly 
limited to the tracts which are its primary seat ; in a large number of 
cases (as has been already indicated) the posterior median columns be- 
come involved ; and generally the internal radicular fibres of the posterior 
roots of the nerves, and more or less of the adjoining parts of the posterior 
cornua get implicated to some extent. Occasionally, also, the disease 



TABES DORSALIS. 



897 



invades the lateral columns, and occasionally even reaches the anterior 
cornua : not, however, Charcot thinks, by gradual involvement of all the 
intermediate tissue, but by extension along the internal radicular fasciculi. 

Symptoms and progress — The invasion of locomotor ataxy is sometimes 
quite sudden ; in other words, impairment of co-ordinating power is the 
first symptom to declare itself. In the great majority of cases, however, 
the specific characters of the disease are only revealed after the patient 
has suffered for an indefinite time, sometimes many years, from premoni- 
tory symptoms. These are very various, but many of them are full of 
significance, and most belong equally to the fully declared disease. The 
more important of them are as follows : First, Pains. These are of vari- 
ous kinds and are referable to different parts. The most common are 
momentary sharp shooting pains, following the course of certain nerves, 
for the most part connected with the trunk or lower extremities. An 
erythematous or vesicular eruption sometimes appears in the areas of dis- 
tribution of the affected nerves. Another variety of pain is of a boring 
or stabbing character, and is generally limited to certain definite regions 
in the neighborhood of the joints or along the back ; and its occurrence is 
usually associated with hyperesthesia of the same parts. A further variety 
is of a constrictive character ; it mostly affects the trunk, but may involve 
the limbs or any part of them. These various forms of pain are often as- 
sociated. The last of them is more or less persistent ; but the others occur 
in momentary twinges, and their continuance is usually affected by a more 
or less rapid succession of such twinges. Sometimes they come on at 
irregular and long intervals, and then not unfrequently continue by suc- 
cessive paroxysms for several hours or several days ; sometimes they recur 
many times daily; sometimes they are constant, and wear the patient out 
by their unceasing severity. They are generally worst at night-time. 
Pains referable to the viscera are also not unfrequent. Among them may 
be included pain in the bladder attended with frequent desire to make 
water, pain in the urethra excited by the act of micturition, and pain in 
the rectum as if the bowel were being distended, associated with violent 
tenesmus. The most important and characteristic of them, however, are 
attacks of gastralgia of extreme intensity, attended with vomiting, faint- 
ness, deranged action of the heart, and an extreme sense of illness. The 
pains in the stomach shoot to the back, about the abdomen, and in various 
other directions. Second, Paralysis o f motor and sensory nerves. These 
are sometimes temporary, and apt to recur at intervals, sometimes perma- 
nent. Among the least common of them are hemiplegia, and anaesthesia 
in the area of distribution of the fifth pair; among the most common, 
paralysis of the external rectus or of the internal rectus or other muscles 
supplied by the third pair. Third, Affections of the eye and ear. We 
have already referred to the fact that the patient may have an internal or 
external squint, or ptosis. It may be added that extreme contraction of 
the pupil is a marked feature of the disease ; that the pupils are sometimes 
unequal ; and that the contracted pupil is apt to dilate under the influence 
of the attacks of pain to which the patient is subject. But besides these 
conditions, which are obvious to casual observers, there are others of yet 
greater significance and importance. The patient's eyesight in many cases 
becomes defective : he sees double ; or his vision gets dim or indistinct, 
and he cannot distinguish small objects or the contours of objects so clearly 
as he formerly did ; or his field of vision becomes contracted, limited per- 
haps to one side ; or there is some failure in the power of distinguishing 
57 



898 



DISEASES OF THE NERVOUS SYSTEM. 



colors — he recognizes yellow and blue, but fails to distinguish red and 
green, and the various secondary tints in the production of which these 
colors are concerned ; or these various conditions are associated in a greater 
or less degree. These affections of the eyesight tend to increase slowly, 
and at length Culminate in absolute blindness. They are due to progressive 
gray atrophy of the optic disk, revealed ophthalmoscopically by chalkiness 
and opacity, with absence of the marginal rosiness of tint, and inability to 
trace the trunk-vessels of the retina as they sink into the substance of the 
optic nerve — they seem to terminate abruptly. The atrophy, according to 
Charcot, is due to a change occurring in the optic disk (identical with that 
which goes on in the posterior columns of the cord) and gradually extend- 
ing backwards along the optic tract as far at least as the corpora genicu- 
lata. Headache referred to the back of the head and forehead, and neu- 
ralgic pains in the course of the branches of the fifth pair, and in the eye- 
ball, frequently attend the above visual lesions. Deafness in one or both 
ears is not uncommon. Fourth, Ajfections of the joints. These are of 
occasional occurrence ; they are observed mainly in the knees and hips, 
.sometimes in the shoulders. They consist in rapid effusion into the joints 
and tissues which surround them, taking place with little or no pain or 
fever, and usually followed at the end of some weeks or months by resto- 
ration to health. Occasionally they end in erosion of the ends of the bones, 
or disorganization of the joints, followed after a time by dislocation. Fifth. 
A curious early symptom has been pointed out by Westphal. When healthy 
persons sit with the legs pendulous, a sharp tap on the ligamentum patellae 
causes sudden contraction of the quadriceps extensor, attended with a cor- 
responding forward movement of the foot. This is due to reflex action. 
In cases of tabes dorsalis this phenomenon is absent almost without excep- 
tion during the whole course of the disease, even in its earliest stages and 
before symptoms of inco-ordi nation have manifested themselves. Lastly, 
among other occasional precursory symptoms may be enumerated : noc- 
turnal incontinence of urine ; spermatorrhoea, sometimes attended with 
erection and voluptuous sensations, sometimes occurring independently of 
erection or of orgasm ; a peculiar aptitude for repeating the sexual act 
many times within a short period ; and, lastly, a permanent acceleration 
of pulse, attended, according to M. Eulenburg, with habitual dicrotism. 

[In addition to the above-mentioned symptoms great brittleness of the 
bones has been observed in some cases.] 

The explanation of the phenomena which have just been enumerated 
is for the most part obvious. They are dependent on the progress and 
distribution of the morbid process which is going on in the nervous cen- 
tres, but which has not yet destroyed, sufficiently to cause obvious inco- 
ordination, those portions of the cord which minister to the co-ordinate 
actions of the lower extremities. Thus the various forms of neuralgic 
pain and cutaneous eruption are due to implication of the intra-rachidian 
portions of the sensory nerve-roots ; the affections of the eyes and ears 
are referable to involvement of the ophthalmic and auditory nerves, or 
their nuclei ; and there are good grounds for believing that the lesions of 
the joints are the consequence of implication of the anterior cornua ; and 
that various phenomena, such as those presented by the pupils and those 
connected with the action of heart and character of the pulse, are of sym- 
pathetic origin. 

The so-called < premonitory' symptoms are in truth an integral part of 
the disease, and if recognized may be taken as sure evidence of the in- 



TABES DORSALIS. 



899 



sidious progress of those central organic lesions which ultimately induce 
the proper ataxic phenomena. Some one or more of these premonitory 
symptoms may continue for years before the occurrence of obvious ataxia ; 
the disease may even stop short with them ; but in many cases those which 
first made their appearance undergo gradual aggravation, others become 
superadded to them, and presently the ataxic phenomena supervene and 
become mingled, as it were, with them. In other cases, again, want of 
co-ordination in the movements of the lower extremities is the very first 
indication of nervous disease, and various of the phenomena hitherto 
spoken of as prodromal appear as complications only during its later 
progress. 

The earliest of the special phenomena of locomotor ataxy is the gradual 
supervention of a certain difficulty in walking, frequently associated with 
more or less numbness and tingling of the toes and feet. The difficulty is 
peculiar in its character; it does not consist in any loss of muscular power 
or any inability to take long walks without discomfort or fatigue, but in a 
certain clumsiness or uncertainty which manifests itself especially when 
the patient first rises from his seat, or when he is endeavoring to avoid 
obstacles, or when he attempts to turn suddenly on his heels, or to go 
upstairs. It becomes especially obvious in the dusk ; and, indeed, the 
very first indication of disease is sometimes the difficulty which the patient 
experiences in walking in the dark. Under all these circumstances, his 
movements become more or less tumultuous, and there is an obvious diffi- 
culty in the maintenance of his equilibrium. This difficulty becomes evi- 
dent in the most marked manner, even in the very earliest stage of the 
disease, when the patient is made to stand blindfold with his feet together. 
At once he begins to totter and to sway, and, unless he opens his eyes or 
is supported by others, soon falls to the ground. With the progress of 
the disease the movements all become more tumultuous, and the difficulty 
of progression increases proportionately; the patient now perhaps expe- 
riences considerable difficulty in assuming the erect posture; in endeavor- 
ing to attain it his legs jerk here and there, apparently urged by an 
uncontrollable impulse, and he has to resort to a stick or the arm of his 
chair, or to a friendly hand to aid him in his efforts. AYhen once he is 
on his legs, he pauses for a while to balance himself, and then starts off 
with his body bent forwards and his legs apart. Every movement of his 
legs is now tumultuous ; the leg with which he steps out is lifted from the 
ground and thrown forwards and upwards with needless suddenness and 
violence, and is then brought down with equally unnecessary force, and 
even when on the ground still presents a tendency to jerk, which may be 
continued even while the other leg is in its turn executing its series of 
awkward progressional movements. The patient continues to walk in this 
manner either without assistance, or with the aid of a stick or chair, or 
between a couple of friends, according to the stage which his loss of co- 
ordinating power has reached. But if he be able to walk alone or with a 
stick, his movements usually become a littls less wild after he has taken a 
few steps ; and he may continue to walk with excessive violence of move- 
ment, no doubt, and with short hurried steps and the body thrown for- 
wards, but nevertheless with considerable power and efficiency. Patients 
in this state will sometimes walk ten, a dozen, or twenty miles at a stretch, 
with comparatively little fatigue ; but in some cases the mere violence of 
his muscular movements involves such rapid exhaustion of power that the 
sufferer can scarcely do more than walk across the room. A time, how- 



900 



DISEASES OF THE NERVOUS SYSTEM. 



ever, comes sooner or later in which his want of control over the move- 
ments of his lower extremities becomes so extreme that it is absolutely- 
impossible for him to make a step or two consecutively or even to stand. 
His legs, when he attempts to use them, move, as Trousseau observes, like 
those of a puppet or a marionette. Thenceforward he is confined to his 
chair or bed. It is a remarkable fact, for the due appreciation of which 
we are indebted to Duchenne, that the muscles of the affected limbs retain, 
as a rule, their bulk, their tonicity, their electrical contractility, and their 
strength, little if at all impaired, not only so long as the patient can walk 
or stand, but long after his limbs have become absolutely helpless. And 
often, at a time when the patient cannot rise from his chair or stand, he 
can freely execute movements of extension and flexion as he sits or lies, 
and successfully resist all manual efforts on the part of his physician to 
extend or flex his legs. The numbness and tingling to which reference 
has already been made generally persist, and for the most part increase in 
degree and extent, and always from below upwards. There is sometimes 
total abolition of cutaneous sensibility in the feet, and there may be some 
impairment of it extending even to the abdomen. Occasionally it is ab- 
sent. This impairment of sensibility gives to the patient the impression 
that his feet are swollen and soft, or that they are enveloped in some thick 
soft covering, and when he stands or walks that he treads on sponge or 
wool, or some other yielding and elastic material, or even that he treads on 
air. However great the loss of tactile sensibility, that which takes cogni- 
zance of differences of temperature usually survives to the last. 

The symptoms of ataxy do not generally remain limited to the lower 
extremities. In most cases, sooner or later, numbness, at first perhaps 
occasional but after a w T hile permanent, is complained of in the tips of one 
or two of the fingers — generally the little and ring fingers; and the numb- 
ness may remain thus limited, or may gradually involve more and more 
of the hand and arm, always, however, continuing most highly developed 
in the parts which were first attacked. In association with this, more or 
less clumsiness in the movements of the fingers, and probably of the hands 
and arms, may be observed. The patient experiences considerable diffi- 
culty in performing all delicate manipulations ; he cannot pick up a pin 
lying upon a hard smooth surface; he cannot button or unbutton his 
clothes or tie a bow, especially if he be unable to direct the operation with 
his eyes; in grasping a pen or any .other similar object which is handed to 
him he first opens his hand wide and then closes it with more or less vio- 
lence upon it, entirely failing to execute those delicate combined move- 
ments which are necessary to the precision of his performance, and which 
impart such grace to the natural movements of the hand. The same 
clumsiness is observable in his efforts to transfer the object from one hand 
to the other, and if it be a pen, in acquiring that hold of it which is proper 
for writing. Further (and this is a defect belonging equally to the lower 
extremities, but less readily recognized in their case), the patient is unable 
without the assistance of his eyes to judge of the position of his hands, or 
so to adjust the action of his muscles as to determine accurately the direc- 
tion or extent of the movements of his arm. Hence, if his eyes be closed, 
he cannot if he wishes to clasp his hands bring them together with any 
certainty; they are brought towards one another at different elevations, or 
one in front of the other, and it is only after several failures have been 
made that they finally meet. Similarly, if he tries to touch his nose with 
his finger, he probably strikes his eye or his forehead or his mouth. The 



TABES DORSALIS. 



901 



voluntary movements of the arms are occasionally effected by a series of 
jerky movements. But notwithstanding the widespread affection of his 
voluntary muscles, he probably during the whole duration of his illness 
retains perfect control over the rectum and bladder, and has no tendency 
to bed-sores. 

Various other phenomena, due mostly to extension or multiplication of 
the nervous lesion, are apt to supervene in the course of the disease. In 
some cases the muscles of the trunk and of the head and neck become im- 
plicated in the same way as the muscles of the extremities, and the patient 
executes slight oscillatory movements when he sits up unsupported. In 
some cases difficulty of articulation comes on ; the patient is slow, yet 
somewhat jerky and indistinct in utterance ; he can pronounce every letter 
perfectly, but fails to pronounce them accurately in combination, and slurs 
Over his syllables. There is often, too, a manifest over-exertion of the 
muscles of the mouth and tongue in the effort to speak, and fatigue is soon 
experienced. In some cases (if such phenomena have not appeared earlier 
in the disease) paralysis of the third, fourth, sixth, portio dura, hypoglossal, 
or vagus of one or other side, comes on ; or double vision, impairment of 
vision, or amaurosis supervenes; or the patient grows absolutely deaf ; or 
he becomes subject to the various forms of pain which have already been 
described ; while, on the other hand, if these have previously existed they 
may disappear. Further, he may now be liable to severe and continuous 
aching pains in the forehead and back of the head, along the spine, and 
in the trunk and extremities, in connection with which, as with the earlier 
neuralgic pains, cutaneous eruptions may appear temporarily ; or he may, 
late in the disease, suffer from retention or incontinence of urine, and 
equivalent conditions affecting the rectum ; and generally he loses sooner or 
later all sexual desire and power. Occasionally, in the far advanced stages 
of the disease, rigidity, contraction, and wasting of muscles come on ; 
complications which are obviously due to the extension of disease from 
the posterior columns to the lateral columns and anterior cornua. 

Locomotor ataxy does not always involve the opposite limbs symmetri- 
cally ; it often commences earlier in one leg than the other, and invades 
one arm in advance of its fellow ; and in the subsequent progress of the 
disease the legs or arms may continue to be unequally affected. The 
course, too, of the disease is very various. Sometimes the symptoms arise 
and succeed one another so rapidly that the patient becomes bed-ridden at 
the end of a few months. But much more commonly the successive phe- 
nomena are slowly and irregularly evolved ; periods of apparent amend- 
ment from time to time intervene ; and ten, twenty, or thirty years may 
elapse before the disease attains its full development. It is more than 
doubtful if absolute restoration to health ever takes place when the clinical 
phenomena are so fully declared as to render diagnosis clear. It is not, 
however, doubtful that many persons do experience great amelioration of 
their symptoms, and that such amelioration is sometimes of long duration. 
Occasionally, indeed, the course of the disease appears to be permanently 
arrested. In the vast majority of cases, however, the progress of the 
patient, except for occasional interruptions, is uniformly from bad to worse, 
until death ends the scene. The causes of death are various. Generally 
it is due to some intercurrent malady ; but it may be referable to implica- 
tion of the muscles of deglutition and respiration, to secondary bladder 
and renal mischief, or the formation of bed-sores. 



902 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment When temporary improvement has occurred under our own 

observation, it has always seemed due simply to avoidance of over-exer- 
tion, rest, protection from cold and wet and other such adverse influences, 
judicious dieting and good hours ; in fact to careful attention to the general 
well-being of the bodily health. It is not clear that any remedy exerts 
any, even the slightest, direct influence over the course of the disease. 
Nitrate of silver has been strongly recommended, iodide of potassium has 
been employed, iron and other so-called nervine tonics are often called 
into requisition. For the relief of pain, sedatives, such as opium or bella- 
donna, or local applications, such as counter-irritants, frictions, and gal- 
vanism, may prove serviceable ; and indeed it may be said generally that 
all complications and all discomforts arising in the course of the disease 
should if possible be relieved. As regards electricity, Duchenne observes 
that faradism and galvanism with intermittent current, are either of them 
often serviceable both in relieving pain and in restoring voluntary power 
to the affected muscles in the earliest stage of the disease. But, while not 
forbidding their employment at a later period, he is evidently not sanguine 
as to the results which are then likely to be obtained. This is in accord- 
ance with general experience. 

G. Glosso-labio-laryngeal Palsy. 

Definition This name has been given by Duchenne to a paralytic 

disorder due to an affection of the medulla oblongata (whence also it has 
been termed paralysie bulbaire) involving mainly the seventh, ninth, and 
spinal accessory nerves, and revealing itself during life by paralysis of the 
lips, tongue, soft palate, and larynx. 

Causation Its causes are as obscure as those of other affections of the 

same class. It has been referred to the effects of cold and moisture, and 
it has appeared to follow upon strong moral emotions. It seems to be a 
disease of adult life, and to affect women more largely than men. 

Morbid anatomy — The essential lesions of this disease are identical, so 
far as regards their nature, with those of locomotor ataxy, lateral sclerosis, 
and the like. They affect, however, a different region. Post-mortem 
examinations conducted on patients dead of this affection have revealed 
sclerosis, with more or less atrophy, of the roots of the spinal accessory, 
hypoglossal, and facial nerves, and sometimes similar changes in the roots 
of the vagi, in the motor roots of the fifth pair, and in the anterior roots 
of several of the upper cervical nerves; but they have also revealed (which 
is of still greater importance) that these changes in the nerves are secondary 
to pigmental atrophy of the large cells contained in the nerve-nuclei situ- 
ated in the medulla oblongata, associated with more or less circumambient 
sclerosis. Certain phenomena in the clinical history of these cases, and 
the fact of the frequent supervention of the symptoms of glosso-labio- 
laryngeal palsy in the course of lateral sclerosis, render it probable that 
the disease, when occurring in the uncomplicated form, is often due less to 
a primary lesion of the nerve-nuclei than to their secondary implication in 
the course of some sclerotic change occupying the anterior pyramids. 

Symptoms and progress. — In most uncomplicated cases of glosso-labio- 
laryngeal palsy the symptoms of the disease come on gradually. The 
tongue usually suffers first. The patient experiences some difficulty in the 
articulation of words, especially of those which need the special employ- 
ment of the tip of the tongue, and presently also more or less difficulty in 



GLO SSO -L ABIO- LARYNGEAL PALSY. 



903 



mastication and deglutition; and he suffers from the accumulation of saliva 
in his mouth. The paralytic condition of the tongue gradually increases; 
he has difficulty in protruding it and in drawing it in again, and ere long 
it lies motionless or nearly so on the floor of the mouth, with its tip behind 
the anterior incisors and its edge pressed and indented against the arch of 
the lower teeth. It is sometimes reduced in size and wrinkled ; sometimes 
it feels large to the patient, and either retains its normal dimensions or 
exceeds them. Whilst the lingual paralysis is in progress, the muscles of 
the soft palate and arch of the fauces become implicated, the patient's 
voice acquires a nasal quality, the difficulty of swallowing becomes aggra- 
vated, and his food is apt to pass into the posterior nares. The arches of 
the palate may occasionally be seen to be unequal, with the uvula pointing 
to one side ; but it is remarkable that even when the paralysis, so far as 
deglutition and enunciation are concerned, is complete, the velum often 
can still be excited by local irritation to violent action. The lips also are 
early involved: the orbicularis becomes enfeebled, the lips get large, the 
lower one pendulous, and it is soon difficult or impossible for the patient 
to close his mouth, to prevent the flow of saliva from it, to utter the labial 
consonants, to whistle or blow out a candle, or to perform any function 
requiring the use of the lips. According to Duchenne, it often happens 
that the quadratus menti and triangularis oris of each side become impli- 
cated, so that the angles of the mouth cannot be drawn down and extended; 
but he says that the buccinators rarely suffer, and that the muscles of ex- 
pression of the upper part of the face remain unaffected, and by their tonic 
contraction so act on the angles of the mouth as to cause the transverse 
elongation of the orifice, and at the same time so deepen and modify the 
direction of the naso-labial sulci as to impart to the patient's physiognomy 
the appearance of crying. Not unfrequently when a patient in this con- 
dition is made to laugh or cry, his mouth becomes widely opened, and 
remains open until the upper lip is restored to its original position by hand. 
The muscles by which the upward and downward movement of the lower 
jaw are effected for the most part retain their normal force, so that the 
patient can bite powerfully up to the last. Nevertheless, difficulty of 
mastication, already extreme in consequence of the paralytic condition of 
the tongue, is enhanced by paralysis of the pterygoid muscles, which ren- 
ders the movements necessary for trituration impossible. Sooner or later 
the muscles of the pharynx and even those of the larynx share in the 
general paralytic affection, and hence the difficulty of deglutition becomes 
further aggravated. 

In the latter stages of the disease the patient ceases to utter any articu- 
late sound, although a laryngeal grunt, indicative of the due action of the 
vocal cords, may attend each effort to speak. The saliva which is con- 
stantly dripping from his lips accumulates in his mouth, becomes sticky 
from long retention, and on opening his jaws, hangs in ropes and festoons 
between the opposite surfaces. His food collects in the buccal pouches, or 
falls out through the open lips, and can only be made to reach the fauces 
either by throwing the head backwards or by pushing the food onwards 
with the fingers. The pharyngeal stage of deglutition is equally difficult. 
Pultaceous matters are swallowed best ; but these have to be passed to the 
back of the mouth in small quantities and with great care ; and even then 
constantly cause choking — either finding their way into the windpipe, or 
into the nose, or being ejected by the spasmodic action of the pharyngeal 
muscles. The entrance of food into the larynx is mainly due to the failure 



904 



DISEASES OF THE NERVOUS SYSTEM. 



of the tongue and epiglottis to descend over the superior laryngeal orifice 
during the act of swallowing; for it is only in somewhat rare cases that 
suppression of the laryngeal voice, indicative of paralysis of the laryngeal 
muscles, is observed. 

Sooner or later, however, the pneumogastric nerves become implicated, 
and then symptoms referable to the respiratory and circulatory organs are 
superadded. Attacks of difficulty of breathing, not due to the entrance of 
food or saliva into the windpipe, are now of frequent occurrence. They 
come on by day or night, and are often provoked by exertion. They do 
not appear to be connected necessarily either with pulmonary disease or 
with any paralytic condition of the ordinary respiratory muscles. Duchenne 
refers them to paralysis of the bronchial muscles. There is no doubt, how- 
ever, that catarrhal affections of the bronchial tubes are now exceedingly 
apt to arise, and that these, however slight they may be, greatly aggravate, 
if they do not induce, dyspnoeal attacks. Remarkable feebleness of circu- 
lation also supervenes at this period ; and especially the patient is liable to 
syncopic attacks, which sometimes accompany the fits of dyspnoea, and are 
attended with precordial anxiety, fear of death, and extreme feebleness, 
irregularity, and generally quickening of the pulse. 

The phenomena above described are all unattended with febrile disturb- 
ance, loss of sensation, pain, giddiness, or any form of mental defect; the 
appetite continues good, the corporeal functions generally are well per- 
formed, and the system at large for the most part retains its powers, ex- 
cepting in so far as they may become impaired by the starvation which the 
difficulty of swallowing gradually induces. Hence some patients who are 
far advanced in the disease will continue to go about the house and even 
to take long walks. In many cases, however, towards the close of life, 
they are confined to the chair or to bed. 

The course of glosso-labio-laryngeal palsy is generally rapid, and its end 
is invariably death, which may come on within six months of its onset, 
and is very seldom delayed beyond three years. The causes of death are : 
starvation from inability to take nourishment; asphyxia, from the impac- 
tion of a lump of solid food at the back of the throat, or from the repeated 
entrance of portions of food or saliva into the larynx ; an attack of dys- 
pnoea or syncope ; and lastly, pulmonary complications — bronchitis and the 
like — which are especially dangerous when involvement of the respiratory 
muscles renders the discharge of bronchial accumulation difficult or im- 
possible. 

Although the glosso-labio-laryngeal palsy conforms in a large number of 
cases to the description which has just been given, it is not unfrequently 
a fragment, as it were, of some more widely diffused nervous disease. Thus, 
as is subsequently pointed out, it often forms one of the complications of 
disseminated sclerosis; its supervention constitutes, almost without excep- 
tion, the last stage of lateral sclerosis ; and, further, it is not uncommonly 
associated with progressive muscular atrophy, generally coming on late, 
but sometimes manifesting itself at an early period. The most important 
cases of the last group are those (and they are not rare) in which the 
respiratory muscles also waste. Again, it is important to recollect that 
groups of symptoms closely resembling those of glosso-labio-laryngeal palsy 
may be caused by effusions of blood into the pons or medulla oblongata, or 
by syphilitic or other disease of the same parts ; and may even arise in 
connection with the descending lesions which follow chronic forms of cere- 
bral disease. 



DISSEMINATED SCLEROSIS. 



005 



Treatment Nothing that we are acquainted with is capable of arrest- 
ing the course of this formidable malady. In the early stages electricity 
may be applied to the enfeebled muscles, and possibly with slight temporary 
apparent benefit. In the later stages we must endeavor to relieve symp- 
toms ; and it may then be of service to feed the patient either by the aid 
of the stomach-pump, or per anum. 

H. Disseminated Sclerosis. (Multiple Sclerosis.) 

Definition 'Sclerose en plaques disseminees' is the name which Char- 
cot (to whom we are mainly indebted for its recognition and description) 
has given to the affection which we here term disseminated sclerosis. Dr. 
Moxson calls it insular sclerosis. It is characterized, post mortem, by the 
presence of a number of small roundish patches of sclerosis, scattered 
irregularly throughout the nervous centres ; clinically, by a variety of 
symptoms, among the most characteristic of which are tremblings of the 
head, neck, trunk, and limbs, coming on only when the muscles are being 
exerted, difficulty of speech, oscillation of the eyeballs, gradually super- 
vening paralysis, with contraction, mainly of the lower extremities, and 
some impairment of the mental functions. 

Causations Disseminated sclerosis is mainly a disease of adult life, 

usually coming on between the ages of twenty and twenty-five, rarely after 
thirty, but sometimes at the period of puberty, and even in childhood. It 
is more common in women than in men. It has been attributed to the 
same causes as those to which other forms of sclerosis have been attributed, 
namely moral influences and exposure to wet and cold. Its advent has 
sometimes been heralded by hysteria, neuralgia, or other nervous symptoms. 

Morbid anatomy Sclerotic patches may appear in the cerebrum, cere- 
bellum, pons, medulla, and spinal cord, either collectively or separately; 
but generally are distributed in several of these organs at the same time. 
In the cerebrum they occupy mainly the neighborhood of the ventricles, 
and are found, therefore, in the corpus callosum, septum lucidum, corpora 
striata, and optic thalami ; they occur also in the centrum ovale, but seldom 
in the gray matter of the convolutions. In the cerebellum, their almost 
exclusive seat is the corpus dentatum. As regards the pons and medulla 
oblongata, they may be either superficial or deep-seated. In the former 
they affect mainly the anterior and inferior aspect, extending thence to the 
cerebral peduncles and corpora albicantia ; in the medulla, they occupy 
all parts indifferently, inclusive of the region forming the floor of the fourth 
ventricle. In the cord, as in the medulla, all parts are liable to be im- 
plicated. The cerebral and spinal nerves sometimes emerge, unaffected, 
from diseased tracts ; in other cases they are studded with similar morbid 
patches, or are involved generally. The cerebral nerves which chiefly 
thus suffer are the first, second, and fifth pairs. The patches of sclerosis 
vary in size, but are for the most part well-defined, and of roundish form. 
They are dense, hard, slightly translucent, and of a grayish color, closely 
resembling that of the healthy gray matter of the brain. They sometimes 
project a little above the general level, sometimes are more or less obvi- 
ously depressed below it. Microscopically they present all the ordinary 
characters of sclerosis; and usually, according to Charcot, may be divided 
into three zones, of which the outermost represents the disease in its 
earliest phase, the innermost represents it in its most advanced condition. 
In the outermost zone, the neuroglia is increased in amount and its nuclei 



906 



DISEASES OF THE NERVOUS SYSTEM. 



in number, and the nerve-tubules are diminished in diameter at the ex- 
pense of the white substance of Schwann ; in the next zone, the neuroglia 
has still further increased and has become distinctly fibrillated, the nerves, 
more widely separated than they were, have become yet more reduced in 
size, and the white substance has almost wholly disappeared while the axis 
cylinder has in many cases undergone enlargement ; in the central area, 
the overgrown neuroglia reigns paramount, the nerve-cells and nerve- 
tubules have for the most part vanished, and those which still survive are 
far advanced in ' atrophy. It may be added : that the gradual disappear- 
ance of the white matter of Schwann involves the production of a large 
number of free oil-globules and granule-cells, which stud the outer two 
zones, and tend to accumulate within the lymphatic sheets of the vessels ; 
that the bloodvessels become enlarged, and the nuclei in their walls in- 
creased in number ; that the nerve-cells undergo pigmental atrophy, shrink, 
and finally disappear; and that corpora amylacea tend to become developed 
in the course of the vessels. 

Symptoms and progress. — The symptoms to which patches of sclerosis 
may give rise must depend partly upon their size, partly on their situation, 
partly on their number. Thus it is obvious : that if a patch of sclerosis 
should interrupt the continuity of the posterior columns of the cord, symp- 
toms more or less identical with those of locomotor ataxy would be devel- 
oped; that if it should involve one of the lateral columns, the symptoms 
referable to it would have more or less resemblance to those characteristic 
of lateral sclerosis ; that if the anterior cornua should be implicated, more 
or less rapid wasting of certain muscles might be expected to follow ; 
that if the medulla oblongata should be its seat, some of the symptoms 
of bulbar paralysis or of glosso-labio-laryngeal palsy would necessarily 
arise; and that if seated in the cerebrum, hemiplegia, convulsions, im- 
pairment of intelligence, or other of the various consequences of brain- 
lesion, would almost certainly follow. It is, further, obvious that if many 
sclerotic patches should be distributed throughout the nervous centres, 
the consequences due severally to them would blend, as it were, into 
a common whole producing collective symptoms of more or less com- 
plexity. 

It is, nevertheless, a fact that a large number of cases of disseminated 
sclerosis, in which the nervous centres are generally implicated, are attended 
with groups of symptoms which collectively afford almost positive proof of 
the nature of the malady which is in progress. [According to Charcot 
and other writers, the disease is met with under three principal forms. 
In the first, or cerebral form, the sclerotic patches are limited to the brain, 
and the symptoms consequently are confined to the parts supplied by the 
cerebral nerves. We shall, therefore, have, in addition to vertigo and 
mental disturbance, nystagmus and defect of speech particularly marked. 
In the second, or spinal form, the seat of the lesion is the cord, and the 
symptoms, therefore, will indicate their spinal origin. In this form trem- 
blings of the limbs, followed by paresis and contraction, occur. In the 
third form, or cerebro-spinal, the disease is disseminated through both 
brain and spinal cord, and we shall have the cases presenting most of the 
features of the other two forms.] We will consider the more important 
of these symptoms successively. 

1. Rhythmical tremors These constitute one of the most distinctive 

features of the disease. They are absent when the patient is asleep, they 
are absent, also, when he lies at rest, with his limbs and head supported ; 



! 



DISSEMINATED SCLEROSIS. 



907 



but they come on whenever he makes any muscular effort, and become 
more and more pronounced the greater and more sustained that effort is. 
When he raises his hand from the bedclothes more or less violent convul- 
sive movements seize his fingers, his hand, and his arm ; if he attempt to 
raise his hand to his lips, these tremulous movements increase ; and if, 
further, the muscular effort be rendered greater by his having to lift some 
heavy body, or something which requires care and precision in handling, 
as, for instance, a glass of water, they are apt to become exceedingly 
tumultuous, and to increase in tumultuousness as the task set him ap- 
proaches completion. Occasionally they are induced when the arm is 
apparently at rest, by the nervous efforts of the patient to keep it still. 
If he sit up unsupported, similar movements affect his trunk and his head 
and neck. If he endeavor to stand or to walk, they become universal, 
and the legs, arms, trunk, and head are all violently agitated. It is not 
pretended that these tremulous movements are present in all cases of dis- 
seminated sclerosis ; but they are present in the great majority of cases. 
Nor must it be assumed that, when present, they are always of general 
distribution ; they may (for a time at least) be limited to one arm, or to 
both arms, or when present in both may affect them unequally ; or the 
• legs may chiefly suffer. Neither must it be supposed that they are present 
during the whole course of the malady. Rhythmical trembling is rarely 
one of the earliest symptoms of the disease ; but it usually comes on 
before long, and then invades the various parts slowly and irregularly ; 
and it disappears as the patient becomes more and more enfeebled, and 
especially when paralysis supervenes. The movements are peculiar ; they * 
are rhythmical, and yet there is some degree of irregularity both in the 
extent of the successive vibrations and in the intervals which separate 
them. They have some resemblance to those of paralysis agitans ; but in 
the latter the vibrations are more rapid, and more regular, moreover, they 
occur when the patient is at rest, and seldom, if ever, directly implicate 
the head and neck. They have a greater resemblance still to those of cho- 
rea, but they are less wanton, less violent, and altogether more rhythmical 
than these; and, further, the vibrations in sclerosis, for the most part, take 
the direction of the general movement of the limb or part which is engaged 
in movement. It must not, however, be forgotten that tremulous move- 
ments, undistinguishable from those of sclerosis, may attend various other 
affections, and especially chronic mercurial poisoning, chronic cervical 
meningitis, and sclerosis of the lateral columns. 

2. Affections of the eyes — Double vision is a not uncommon symptom 
of the earlier stages of sclerosis, as it also is of locomotor ataxy, but is for 
the most part transitory and unimportant. Indistinctness of vision is a 
much more frequent phenomenon, and is generally permanent, but rarely 
ends in blindness. It is often present when no signs whatever of disease 
can be detected with the ophthalmoscope. But sometimes more or less 
advanced atrophy of the optic disk is present, which becomes complete in 
cases of total blindness. Nystagmus is a symptom of considerable im- 
portance, and is present in about half the total number of cases ; it con- 
sists in consensual small oscillations of the eyeballs, which in slightly 
advanced cases may be apparent only at the moment when the patient 
endeavors to fix his glance upon some fresh object, or looks out of the 
corners of his eyes ; but they are generally constant, although aggravated 
by voluntary movements of the eyeballs. They cease when the patient is 



908 



DISEASES OF THE NERVOUS SYSTEM. 



asleep, or when his eyes are shut in repose. Nystagmus is rarely present 
in locomotor ataxy. 

3. Defect of speech — This is nearly constant. In well-marked cases 
the utterance is slow and drawling. The words (to use Charcot's expres- 
sion) are ' scanned,' as it were, there is a pause after each syllable, and the 
syllables themselves are slowly evolved. Moreover, they are imperfectly 
pronounced, certain letters or difficult combinations of letters being slurred, 
and sometimes to such a degree that speech becomes unintelligible. Fur- 
ther, the lips and tongue are often tremulous : the lips tremble previous to 
the utterance of articulate sounds, and during the course of utterance ; 
and the tongue when it is protruded is in constant fibrillar movement. 
This tremulousness of the organs of speech adds to the difficulty of articu- 
lation, and imparts to it a peculiar tremulousness or uncertainty. A very 
similar defect of speech is apt to accompany locomotor ataxy, but in that 
case the tremulousness of the lips and tongue is absent, and (at least ac- 
cording to our observation) the muscular efforts to utter articulate sounds 
are unnecessarily violent. 

4. Vertigo is an early symptom in about three-fourths of the total num- 
ber of cases. It is mostly gyratory, and generally comes on in paroxysms 
of short duration, but is sometimes almost continuous. It often interferes 
seriously with locomotion. The presence of nystagmus is also a cause of 
vertiginous sensation, the oscillations which take place in the eyeballs 
being referred by the patient to the objects which are figured on his retina?. 
Vertigo is not common either in tabes or in paralysis agitans. 

5. Paresis of the limbs, and more especially of the lower extremities, 
comes on at an early stage of the disease. It generally begins in one leg. 
This feels weak and heavy, and drags in walking, but there are no move- 
ments indicative of inco-ordination. Soon the other leg becomes affected ; 
but even then (so different from what occurs in tabetic patients) so long 
as he has sufficient strength to stand, he is capable of maintaining his 
equilibrium even when his eyes are shut. The weakness subsequently 
extends to the arms. This enfeeblement of the limbs gradually increases 
until it culminates in absolute motor paralysis; the convulsive oscillations 
of the earlier period undergoing proportionate diminution until they finally 
cease. The paralysis which commences in the lower limbs becomes as a 
rule complete in them while the arms are yet comparatively little involved. 
The patient not unfrequently complains of some degree of tingling and 
numbness, but there is rarely if ever any obvious impairment of cutaneous 
sensibility. Moreover, the muscular sense remains unaffected, so that he- 
recognizes exactly the position of objects and the amount of force neces- 
sary to accomplish various voluntary movements. There is no paralysis 
of the bladder or rectum ; the affected muscles retain their form, bulk, and 
tonicity ; and reflex and electrical contractility are unimpaired. [The 
tendon reflexes are often exquisitely developed in this disease.] The pare- 
tic condition of the limbs is liable to remissions. 

6. Contraction of limbs At some period or other in the course of the 

paretic symptoms, the lower extremities, either spontaneously or under 
excitement, become suddenly stiffened in extension, and pressed one against 
the other. These attacks may last some hours, or even some days, and 
are at first separated from one another by comparatively long intervals. 
But by degrees the intervals shorten, and at length ceasing, the rigidity 
of the muscles becomes permanent. At this period the thighs are extended 
on the trunk, the legs on the thighs, the feet on the legs, and the members 



DISSEMINATED SCLEROSIS. 



909 



lie in close apposition and cannot be separated. Sometimes the flexors 
overcome the extensors, and the limbs are flexed at all the joints. Occa- 
sionally, but at a later period, the arms become rigid and pressed against 
the sides of the body. At this time violent tremblings, lasting for a few 
minutes or even longer, are apt to arise in the stiffened limbs. These 
seem sometimes to come on spontaneously ; but they may be excited by 
exposure to cold, or by pricking, tickling, electricity, or other forms of 
irritation ; and they may extend from the limb in which they were first 
induced to the opposite limb, and even cause general trembling of the 
body. They may be at once stopped, according to Brown-Sequard, by 
forcibly flexing the great toe. This stiffening of the limbs may be de- 
veloped while their movements are still in some degree under the control 
of the patient, and does not therefore necessarily incapacitate him from 
walking with assistance. 

7. Expression and mental condition. — During the course of the disease 
a marked change in the expression is apt to come on. The patient's glance 
is vague and uncertain, his lips pendulous and apart, his general aspect 
sad, weak, or fatuous. At the same time there is some change in his 
mental condition ; the memory fails, the conceptions are slow, and the 
intellectual and affective faculties generally impaired. He is stupidly in- 
different to all that goes on about him, and is apt to laugh or cry without 
occasion. Sometimes he becomes maniacal or demented. 

One or more of the symptoms which have just been enumerated may 
fail in a greater or less degree in certain cases. But, on the other hand, 
additional phenomena are not unfrequently superadded. We have already 
suggested as possible complications certain phenomena which actually do 
i not unfrequently present themselves in the course of the disease : namely, 
i inco-ordination of the movements of the lower extremities, and even of the 
\ hands and arms; wasting of certain of the voluntary muscles; and diffi- 
culties of deglutition, respiration, and circulation, indicative of involvement 
of the medulla oblongata. But, further, apoplectiform attacks are not 
unfrequent. These may come on without warning, or may be preceded 
by rapid failure of the mental faculties. They recur as a rule several 
times at irregular and long intervals. They are often attended with con- 
vulsions, which are usually unilateral, or with hemiplegia, associated some- 
times with flaccidity, sometimes with rigidity of the paralyzed muscles. 
In these attacks the pulse becomes greatly accelerated, and the tempera- 
ture of the internal parts rises rapidly, so that probably in the course of 
the first few hours it mounts to 102°, and within twenty-four hours to as 
much as 104°. If the case is about to prove fatal, the temperature may 
reach 108° or 109°. In these cases bed-sores also are apt to form with 
great rapidity upon the sacral region. These apoplectiform attacks (which 
are not peculiar to disseminated sclerosis, but occur equally in cases of 
general paralysis and tumors of the brain, and in cases in which embolic 
softenings or apoplectic effusions have left chronic lesions behind them) 
j are distinguishable from those due to hemorrhage by the fact of this sud- 
\ den and rapid rise of temperature. 

Charcot divides the clinical history of cases of disseminated sclerosis 
j into three periods. The first extends from the first appearance of symp- 
toms down to the supervention of rigidity of the limbs. The second in- 
I eludes all that time subsequent to the first appearance of rigidity during 
j which the patient's symptoms undergo gradual aggravation, but during 



! 



910 



DISEASES OF THE NERVOUS SYSTEM. 



which the organic functions as yet maintain their integrity. The third 
commences with the failure of the nutritive functions. 

First period. — The mode of invasion is various. Sometimes the disease 
commences with symptoms referable to the brain, such as vertigo, or dip- 
lopia, soon followed by embarrassment of speech and nystagmus. More 
commonly the first symptoms are spinal, especially weakness of the lower 
extremities, which may continue for months or even for years before it 
becomes complicated with other phenomena. This weakness is liable to 
remissions, and is usually unattended with pain, loss or impairment of 
sensation, or difficulty of micturition or defecation. It presents nothing 
distinctive. Barely the disease commences with symptoms like those 
which usher in locomotor ataxy. The early progress of the disease is 
usually slow, but now and then the symptoms appear and follow one another 
with great rapidity. The contraction of the limbs, the supervention of 
which terminates this stage, does not usually show itself till after the lapse 
of two, four, or even six years. 

Second period This is usually of long duration. During it all the 

characteristic symptoms of the disease are present and undergo gradual 
aggravation, until the patient becomes utterly helpless and confined to his 
chamber or his bed. 

The third period comes on with progressive weakening of the organic 
functions. At the same time some of the symptoms proper to the disease 
come into special relief. Intelligence fails ; the patient becomes, perhaps, 
fatuous ; the sphincters cease to act, and the evacuations are all passed 
unconsciously ; the bladder inflames ; bed-sores form ; and appetite for 
food declines. At this time, also, various intercurrent maladies are apt to 
come on, such as pneumonia, dysentery, or diarrhoea, or difficulty of deglu- 
tition with other signs of involvement of the medulla oblongata. 

The duration of the cerebro- spinal form of the disease usually varies 
between six and ten years ; but if the cord only be affected, life may be 
prolonged for twenty years or more. The causes of death are numerous. 
Among the more important may be enumerated: apoplectic attacks, the 
consequences of affection of the medulla, pneumonia and other intercurrent 
disorders, inflammation of the bladder, bed-sores, and debility from failure 
of the nutritive powers. 

Treatment This appears always to have failed. Charcot observes 

that both strychnine and nitrate of silver have served for a time to check 
the trembling of the muscles, but have had no permanent good effect. 
Arsenic, belladonna, ergot of rye, and bromide of potassium have all been 
used at various times, but without obvious beneficial results. Little that 
is favorable can be said even of hydropathic treatment, or faradism, or the 
continuous current. 



YI. PARALYSIS AGITAXS. (Shaking Palsy.) 

Definition. — This is a disorder mainly of advanced life and of chronic 
progress, characterized especially by trembling of the limbs arising inde- 
pendently of voluntary movements, and for the most part sparing the head 
and neck. The patient in an advanced stage, without vertigo, is unable 
to maintain his equilibrium when walking. 



PARALYSIS AGITANS. 



911 



Causation — The causes of paralysis agitans are various. It would seem 
to be not unfrequently brought on more or less suddenly by violent emotion, 
such as terror, grief, rage, and the like. It is often referred, and probably 
with truth, to long-continued exposure to cold and wet. And it is asserted 
that it is occasionally traceable to wounds or bruises involving peripheral 
nerves ; in favor of which statement is the fact that severe neuralgic pains 
referable to such injuries have been succeeded by trembling of the parts 
involved, and subsequently by the general phenomena of paralysis agitans. 
There is little proof that the disease is hereditary. Neither does it belong 
to one sex more than the other. It is for the most part a malady of ad- 
vanced life, usually first making its appearance after the age of forty. It 
may, however, occur at an earlier period, and cases are on record in which 
it commenced at twenty or even sixteen. 

Morbid anatomy — Of the condition of the nervous system in this affec- 
tion nothing definite is known. Previously to Charcot's investigations, 
paralysis agitans and disseminated sclerosis were usually confounded with 
one another, and the lesions of the latter disease were consequently re- 
garded as having an important connection with the clinical phenomena of 
the malady now under consideration. In cases, however, of true paraly- 
sis agitans no constant lesions, sufficient at all events to explain the pecu- 
liarities of its symptoms, have yet been discovered. In some recent ex- 
aminations of Charcot's, there were found obliteration of the central canal 
of the cord by increase of its epithelial lining, overgrowth of the nuclei 
which surround the ependyma, and marked pigmentation of the nerve-cells, 
chiefly those of Clarke's posterior vesicular columns. It must be observed, 
however, that post-mortem examinations in cases of this disease are almost 
necessarily made on persons far advanced in life, in whom, therefore, on 
other grounds such changes as are here referred to are likely to be met with. 

Symptoms and progress — The symptoms of paralysis agitans may come 
on gradually or suddenly. In the great majority of cases the onset of the 
disease is insidious. The part attacked is the hand or foot, or the thumb. 
If the hand be affected, its different segments oscillate on one another in 
a manner which is almost distinctive. The thumb moves on the other 
fingers as in the act of twisting wool, rolling a pencil, or crumbling bread. 
If the affection involve also the rest of the upper extremity, these move- 
ments of the fingers are associated with similar rapid backward and for- 
ward movements of the hand as a whole on the forearm, and of the fore- 
arm on the upper arm. At this period of the disease the trembling is often 
transitory. It comes on occasionally only, and maybe at long intervals. 
It comes on, moreover, when it is least expected — when the patient is at 
complete rest, mentally and bodily ; and it maybe arrested by an effort of 
the will, and often ceases when he walks, or when he uses the affected limb 
for writing, lifting a weight, or other purposes. The trembling may be 
confined for an indefinite time to the part first attacked. But it generally 
spreads sooner or later : first, if a part only of a limb have been involved, 
to the rest of the limb, and subsequently, and often after longish intervals, 
to other limbs. It usually assumes in the first instance the hemiplegic 
form, affecting first the arm and then the leg of the same side, and 
extending later to the arm and leg of the opposite side. Sometimes it 
puts on the paraplegic character, spreading from one leg to the other, be- 
fore the upper extremities get involved. It seldom extends from one arm 
to the other, leaving the legs unaffected, or from the arm of one side to the 
leg of the opposite side. In some cases tremulousness is not the first symp- 



912 



DISEASES OF THE NERVOUS SYSTEM. 



torn of which the patient complains. But its occurrence is preceded for a 
longer or shorter time either by a sense of profound fatigue, or by rheu- 
matic or neuralgic pains referable to the limb or part of a limb in which 
convulsive movements subsequently manifest themselves. In rare instances 
the affection comes on suddenly, with tremulousness either of a single limb 
or of all the limbs. Under these circumstances it may subside at the end 
of a feAV days. But other similar attacks are liable to follow at decreasing 
intervals, until ultimately the disease becomes established. The duration 
of the initial stage to which the above account refers varies usually from 
one to two or three years. 

When paralysis agitans has attained its complete development the trem- 
bling not only involves several limbs, and probably all of them, but is also 
(at all events in severe cases) almost incessant. It is liable, however, to 
remissions and exacerbations, the latter of which seem to be often induced 
by emotional disturbance or muscular exertion, yet not unfrequently come 
on without obvious cause. Natural sleep, or that induced by chloroform, 
is always attended with entire cessation from convulsive movements. It 
is at this period that the tremors put on their most distinctive characters. 
They consist of involuntary rhythmical oscillations, which have little am- 
plitude, follow one another rapidly, and present considerable uniformity ; 
and which, when the hand is involved, give to its different segments the 
aspect of being collectively engaged in the performance of some delicate 
process or operation. The head and neck remain as a rule free from con- 
vulsion. So far indeed from being agitated, the muscles of the face are 
immovable, the look is fixed, and the features present a permanent aspect 
of sadness or hebetude. Nystagmus, so common in disseminated sclerosis, 
is absent here. The muscles of the jaw also are free from movement, but 
the tongue, when protruded, not unfrequently presents well-marked tremu- 
lousness. There is no real failure of language, but speech is slow, hesitating, 
laborious, as though the enunciation of each syllable were attended with con- 
siderable effort. It may, however, become tremulous in consequence of 
the transmission of the tremulousness of the limbs to the head and neck. 
Deglutition is performed without, difficulty, but is perhaps somewhat slow ; 
and often in old cases saliva tends to accumulate in the mouth. Respira- 
tion does not suffer. 

A striking phenomenon of the disease, to which Charcot has especially 
called attention, is rigidity of the muscles, which comes on for the most 
part late in the malady, though occasionally at its commencement. It 
affects the muscles of the extremities, trunk, and neck. The supervention 
of this rigidity is attended with cramps, followed by contraction, which is 
at first transitory, but after a time becomes persistent, though even then 
liable to exacerbations. The flexor muscles suffer in the chief degree. 
The rigidity and contraction becoming permanent give a peculiar aspect 
to the patient. The head is thrown strongly forwards and fixed in that 
position; and the trunk, when the patient stands, is bent in the same 
direction. The elbows are separated a little from the trunk ; the forearms 
are slightly flexed on the upper arms ; and the hands, similarly flexed on 
the forearms, rest upon the waist. The hands, moreover, are more or less 
deformed; usually the fingers are slightly flexed in mass at the metacarpo- 
phalangeal joints, with an inclination to the ulnar side of the arm, and 
with the thumb resting against the forefinger as in the ordinary position for 
writing; but in some cases the fingers, though substantially occupying the 
same position, are flexed at the proximal and distal joints, but extended at 



PARALYSIS AGITANS. 



913 



the middle joints. The rigidity of the lower limbs is such as sometimes 
to give the appearance of paraplegia with contraction ; the feet are occa- 
sionally in the position of talipes equino-varus, and the toes bent into the 
form of a claw. The patient, however, retains the power of voluntary 
movement, and the muscles are never thrown into the tetanic spasms 
which are so common in many spinal diseases. 

The difficulty of movement which characterizes patients suffering from 
shaking palsy is due no doubt in some degree to the muscular rigidity and 
contraction which have just been described. But it often manifests itself 
long before the rigidity has become particularly obvious. 

The same peculiarity attends speech. It would seem that unwonted 
efforts are needed for the transmission of the motor impulses ; and indeed 
the slightest movements are followed by extreme fatigue. This group of 
phenomena has been taken to imply the existence of true paralytic weak- 
ness. But it is not so, for on testing the strength of different limbs by the 
dynamometer, it has been often found, that (excepting in the case of 
patients in the last stage of the malady) muscular force is remarkably pre- 
served. Sometimes, indeed, the muscles of the most tremulous and appa- 
rently weakest limb are really more powerful than those of its seemingly 
healthier fellow. 

The mode of walking in paralysis agitans is usually highly characteristic 
of the disease. The patient rises perhaps with difficulty from his seat, 
then steadies himself for a few seconds, and at length, with his head and 
trunk in advance, runs straight forwards in spite of himself with rapid 
steps. He appears to be losing his equilibrium, and running forward to 
regain it; and not unfrequently falls down. This difficulty of maintaining 
his balance in walking is not wholly due to the position which his body 
generally assumes, for it may occur while he is yet capable of retaining 
the erect posture ; and, further, in some cases the patient has a tendency 
to fall or run backwards even when his body is bent forwards. Neither is 
it connected with the presence of vertigo, for the patient does not as a rule 
suffer from this sensation. 

Various other symptoms besides those which have been enumerated 
complicate the course of shaking palsy. Patients usually complain of a 
sense of persistent tension or traction in the affected muscles, or of cramps ; 
they experience a feeling of prostration or utter fatigue which especially 
comes on after fits of trembling ; or they are the victims of an undefinable 
malaise or fidgetiness. They want incessantly to shift their position ; and 
if they be not assisted in their desire their sufferings become unendurable. 
They suffer most in this respect at night and when in bed. Another cause 
of suffering is an habitual sensation of excessive heat, referred mainly to 
the epigastrium and back, but not limited to these situations. It varies 
in intensity, and is usually most severe after the occurrence of a paroxysm 
of trembling. It is not attended with any actual elevation of temperature. 
Cutaneous sensibility is in no degree affected. The patient retains his 
mental faculties and the power over his rectum and bladder. 

The final stage of the disease supervenes for the most part at the end of 
some years. It is indicated : by aggravation of the difficulty of move- 
ment, the patient being consequently compelled to keep his room or his- 
bed; by failure of nutrition in which the muscles chiefly suffer, occasion- 
ally becoming fatty; by impairment of intelligence and of memory; by 
general prostration; and by the formation of bed-sores. At this time the 
convulsive movements not unfrequently cease. Death res-ults sometimes' 
58 



914 



DISEASES 



OF THE NERVOUS 



SYSTEM. 



from gradual asthenia, more commonly from the supervention of some 
other disorder, especially pneumonia. The duration of the disease may 
extend to twenty or thirty years. 

Treatment. — All kinds of treatment have been employed, but, for the 
most part, with little success. Among the medicines which have been 
recommended may be named iron, nitrate of silver, chloride of barium, 
arsenic, zinc, strychnia, ergot of rye, belladonna, opium, hyoscyamus, and 
Calabar bean. Of these, iron is advocated by Elliotson, and has perhaps 
been instrumental in improving the general health of patients ; and strych- 
nia has been lauded by Trousseau, but seems to have been found injurious 
by Charcot. The only one of the sedative drugs which the latter author- 
ity thinks serviceable is hyoscyamus, and this effects no permanent improve- 
ment. Warm baths, cold baths, and shower-baths are also sometimes of tem- 
porary service. Electricity has been largely employed, but the only form 
which seems to have been of real efficacy is the constant current. A few cases 
of recovery under its use have been recorded. [In one case, slight im- 
provement followed upon long-continued rest in bed, and the use of small 
doses of bichloride of mercury.] It must not be forgotten, however, that 
cases which have not advanced beyond the early stage occasionally get 
well spontaneously. On the other hand, this fact justifies the hope of 
benefit from judicious treatment. Hygienic measures should never be 
neglected. 



VII. PSEUDO-HYPERTROPHIC PARALYSIS. 

Definition This is a form of paralysis, first recognized and described 

by M. Duchenne, occurring in children, and attended with remarkable 
enlargement of some of the paralyzed muscles. 

Causation — It has hitherto been observed in childhood only, and almost 
exclusively in boys. It has been met with also in several children of the 
same family. But beyond these facts nothing whatever is known in refer- 
ence to its causation. 

Morbid anatomy — The morbid process, so far as the muscles are con- 
cerned, appears to consist mainly in the gradual growth of connective tis- 
sue in the interstices between the ultimate fibres' ; this becomes abundant 
and dense, and in some cases the seat also of the formation of fat. It is 
to this overgrowth that the apparent hypertrophy of the muscles is due. 
The muscular fibres appear to dwindle away under the influence of the 
pressure to which they are subjected ; and, although retaining their trans- 
verse striation for a long period, at length undergo degenerative changes 
— the transverse striae becoming indistinct, or effaced, longitudinal mark- 
ings perhaps unusually apparent, and more or less abundant deposit of 
granular or fatty matter taking place. The condition of the muscles in the 
earliest stage of the disease has been less thoroughly investigated than 
their condition in the later periods. M. Duchenne believes that at that 
time there is an oedematous state of the tissue which itself causes a certain 
amount of increase of volume. 

Symptoms and progress. — The course of pseudo-hypertrophic paralysis 
has been divided by M. Duchenne into three periods. Of the first but 
little is certainly known, for its symptoms are slight, and children are 
rarely at that time brought under medical treatment ; moreover, the symp- 



PSEUDOHYPERTROPHIC PARALYSIS. 



915 



toms are in no degree distinctive of the disease, and are apt, therefore, to 
be misunderstood. The first symptoms appear to be due to gradual en- 
feeblement of the muscles of the lower extremity and perhaps of those of 
the back. The child presents certain peculiarities of gait. He stands 
with his legs w r idely separated, and his shoulders thrown back, probably 
beyond the buttocks, the concavity of the small of the back being corres- 
pondingly deepened ; he also walks with his legs apart, 
lifting the knee of his advancing leg needlessly high, 
while the foot is more or less extended, and the toes 
point downwards, and swaying his body from side to 
side in association with the peculiar position and move- 
ment of his lower extremities. This stage, according 
to M. Duchenne, usually varies in duration from a few 
months to a year. It may, however, be delayed, or 
it may so speedily merge in the second stage as to be 
unappreciable. 

The second stage is marked by the gradual exten- 
sion of the disease and the enlargement of certain 
muscles. The paresis, which probably always com- 
mences symmetrically in the lower extremities, grad- 
ually mounts, involving successively the muscles of 
the back and of the trunk generally, the muscles of 
the arms, and, in some cases, those of the face — more 
especially the temporals and masseters. Possibly some 
fulness of the calves may already have been apparent 
in the first stage ; but now they augment rapidly and 
considerably in volume; and by degrees various other 
groups of muscles become similarly affected. The 
degree of enlargement and its distribution differ in 
different cases. In some, only the calves become 
hypertrophied, w r hile the muscles of the rest of the 
body either retain their normal bulk, or shrink ; in 
some, the calves and buttocks are the chief seats of 
overgrowth ; in some, the increase of bulk involves 
all the muscles of the lower extremities, together with 
the posterior muscles of the spine ; in some, again, the deltoids share in 
the widely-diffused hypertrophy ; and occasionally all the muscles of the 
limbs and trunk become enormously increased in volume, and the child 
(though so feeble, perhaps, that he can scarcely move) acquires the appear- 
ance of an infant Hercules. This enlargement of the muscles, even if it 
be limited to the calves, is a very striking phenomenon ; especially when, 
as in these cases, it goes along with progressive loss of muscular power. 
During the progress of this stage, the phenomena which have already 
been referred to as attending the acts of standing and walking, become 
more pronounced; the legs are kept widely apart; the shoulders are thrown 
far backwards ; and the peculiar swaying of the body from side to side, 
which attends the efforts to raise and project the legs successively forwards, 
becomes considerably exaggerated. Moreover, the child has the greatest 
difficulty in rising from the ground on which he is sitting into the upright 
posture ; he gets on all-fours, then protrudes his buttocks like a dog in the 
act of stretching, and probably finds all his efforts fruitless unless he can 
manage to raise his head and shoulders hand over hand by means of a 
chair or bedstead. This stage attains its full development in a year or a 




Portrait of a boy suf- 
fering from pseudo-hy- 
pertrophic paralysis. 



916 



DISEASES OF THE NERVOUS SYSTEM. 



I 



year and a half, and may then continue with little change for two or three 
years more. 

The third stage is characterized by extension of paralysis to the upper 
extremities, supposing these to have escaped hitherto ; by arrest of the 
progressive enlargement of the muscles ; and possibly even by their dimi- 
nution. The child grows more and more helpless ; the voluntary eleva- 
tion of the arms becomes difficult and at length impossible ; and he grad- 
ually loses all power in his lower extremities, and is hence condemned to 
pass the rest of his existence on his chair or in bed. Since respiration, 
circulation, and digestion remain unaffected, life may be sustained in this 
condition for a considerable period ; but sooner or later the vital powers 
of the patient become prostrated, and pneumonia or some other intercur- 
rent affection carries him off. Death usually occurs during the period of 
adolescence. 

In order to complete the picture of the disease, two or three other facts 
in relation to these patients must be mentioned. No febrile symptoms 
manifest themselves at any period of the disease. The muscles in the 
early stage retain their electro-contractility almost unimpaired ; but later 
on, as their fibres undergo degeneration, electro-contractility necessarily 
dies out. It has been shown by Dr. Ord that the temperature of the legs, 
in cases in which the calves are hypertrophied, is three or four degrees 
higher than that of the thighs, a fact which he connects with the active 
growth of fibroid material taking place between the muscular fasciculi. 
It has often been observed that children afflicted with this disease are or 
become defective in their intelligence ; and that, if they be attacked before 
they have learned to speak, they are slow in learning to speak, and im- 
perfect in their articulation. Lastly, there is no impairment of sensation, 
and no loss of control over the bladder or rectum. 

Pathology. — Notwithstanding the symmetrical character of pseudo- 
hypertrophic palsy, its tendency to become generalized, and its association 
with impaired intelligence, there is no sufficient reason to regard it as of 
nervous origin. For no lesions whatever have been detected in the 
nervous centres or in the nerves ; while the absence of rigidity, inco- i 
ordination, and rapid wasting, and the retention of sensation, control over 
the sphincters and muscular contractility, equally point to integrity of the 
spinal cord. On the other hand, in the muscles themselves, progressive 
changes have been discovered which are ample to explain the main phe- 
nomena of the disease. 

Treatment — According to M. Duchenne, pseudo-hypertrophic paralysis 
may sometimes be cured or arrested in its first stage by muscular faradism, 
aided by baths and kneading, or shampooing. When once, how r ever, dis- 
tinct enlargement of muscles has taken place, no treatment that has yet 
been adopted avails to delay the fatal progress of the disease. 



VIII. MORBID GROWTHS. ANEURISMS. ENTOZOA. 

Various forms of adventitious growths affect the nervous centres or 
structures in relation with them. It is quite impossible, however, to 
distinguish them from one another during life by reference simply to the 
nervous symptoms which they induce. It is needless, therefore, for clini- 



MORBID GROWTHS. 



917 



cal purposes, to discuss each variety separately ; and we shall content our- 
selves with first giving a brief sketch of some of the most striking patho- 
logical phenomena which the more important forms of growths present, 
and then discussing the clinical history of such tumors as a whole. 

Morbid anatomy — 1. Tubercle. In a strictly scientific arrangement 
of disease, we ought of course to include under this head miliary tubercles 
j of the pia mater. We have considered these, however, elsewhere in asso- 
j ciation with meningitis, which they generally induce, and independently 
of which they rarely if ever cause symptoms. The variety of tubercle 
which we have now specially to consider is that which originates within 
the nervous substance and forms tumors there varying from the size of 
(say) a pin's head to that of a fowl's egg. They are well defined, rounded, 
or lobulated masses, opaque, of a yellowish or greenish tinge, with much 
of the consistence and aspect of cheese. They correspond pretty exactly 
to the description usually given of typical yellow or crude tubercle ; but, 
although they may become disintegrated at points, they seldom, if ever, 
break down into cavities. They are made up of an aggregation of smaller 
masses, and differ in no important respect from the tubercular aggregates 
which in cases of tubercular meningitis are found along the vessels or in 
the depths of the sulci, and are the result of the coalescence of miliary 
tubercles. They may be solitary, or may exist in large numbers ; and 
they may occur in any part of the nervous centres, involving, however, 
by preference the gray matter both of the brain and of the cord. No 
doubt, from their large size, the cerebral lobes are pre-eminently liable to 
suffer. But tubercles have also a remarkable aptitude to form in the sub- 
stance of the cerebellum; and then (according to Andral) in the ascending 
order of frequency in the pons, medulla oblongata, spinal cord, peduncles 
of cerebrum and cerebellum, optic thalami, and corpora striata. They 
are much more common in the upper part of the cord than in the lower 
part. Tubercular tumors of the brain appear to occur more frequently in 
boys than girls, and are rarely met with either in adults or in children 
under two years of age. They occur most commonly between the ages 
of three and seven. Tubercle of the nervous centres is probably always 
associated with tubercle in other parts; and, although ordinarily there is 
no connection between them, tubercular meningitis sometimes supervenes 
on the presence of tubercular masses of old date in the substance of the 
brain. 

2. Syphilis. — The ordinary seat of intracranial syphilis is the dura 
mater. The disease may involve the outer aspect of that membrane, in 
which case it is usually associated with disease of the bones of the skull, 
and affects the brain mainly by pressure. Or it may involve the substance 
of the membrane, or its inner aspect, leading to the development of hard 
dense gummata which may be solitary or multiple, localized or scattered 
over a considerable extent of surface, and may vary individually from the 
size of a hazel-nut downwards. These tend gradually to involve the con- 
tiguous structures. The visceral arachnoid becomes adherent to them, 
and not unfrequently similar growths then develop in the subarachnoid 
tissue and pia mater. Subsequently the subjacent brain suffers, becoming 
first indented, and then either softened or the seat of gummatous growths. 
The parts of the dura mater which are most commonly affected are those 
corresponding to the convexity of the hemispheres, and those in relation 
with the anterior and under surface of the brain, more especially in the 
neighborhood of the sella turcica, whence the disease may spread to the 



918 



DISEASES OF THE NERVOUS SYSTEM. 



surface of the petrous portions of the temporal bones and to the tentorium 
cerebelli. 

Gummatous tumors originating in the pia mater or in the substance of 
the brain are much less common than the last, and as a rule are softer 
and more transparent and jelly-like ; they are usually of small size, but 
may attain the bulk of a hen's egg. Those which are developed primarily 
from the pia mater affect mainly the under aspect of the brain, more espe- 
cially between the optic commissure in front and the pons behind, and in 
the course of the cerebellar peduncles. These, too, are the situations in 
which they attain their greatest bulk. Tumors of the substance of the 
brain arise chiefly in the hemispheres, and the larger ganglionic masses, 
especially the optic thalami. After these parts they affect mainly the pons 
Varolii and the cerebral and cerebellar peduncles. It is an important 
fact that syphilis, whether of the dura mater, pia mater, or nervous tissue, 
has a marked tendency to affect the parts at the base of the brain, and 
consequently to implicate the nerves there situated. Although there are 
good clinical reasons for believing that the cord and its membranes are not 
unfrequently the seat of this disease, there are but few published cases in 
which the diagnosis has been verified by post-mortem examination. 

It is not rare for the cerebral arteries in connection with syphilitic 
growths to become obstructed with thromb' ; but it also not unfrequently 
happens, in cases of secondary or tertiary syphilis, that, independently of 
the formation of gummata, the walls of certain of the arteries at the base 
of the brain become thickened, indurated, and translucent, and the chan- 
nels subsequently obstructed, partly from this thickening of the walls, 
partly from thrombosis. 

3. With respect to other neoplastic formations, notwithstanding the im- 
portance and frequency of some of them, we need not, for many reasons, 
go into much detail. They are mainly the following: fibroma, psammoma, 
melanoma, and cholesteatoma (to which, on account of their rarity or of 
their insignificance in a clinical sense, we shall make no further reference), 
and myxoma, glioma, sarcoma, and cancer. 

a. Myxomatous tumors are not altogether unfrequent. They some- 
times originate in the membranes of the brain or cord, sometimes in the 
cerebral substance. Their most common seat, however, is the cerebral 
hemispheres, where they form transparent gelatinous growths, which often 
become cystic, and tend to acquire large dimensions. They may attain 
the size of a man's fist. 

b. Gliomatous tumors, also, are not unfrequent, and, indeed, are almost 
special to the nervous centres. They are grayish or pinkish in tint, 
translucent and highly vascular, infiltrate, as it were, the tissues in which 
they are found, and blend insensibly with them at their edges. Moreover, 
though varying somewhat in color, transparency, and density, they have 
a considerable resemblance to the gray matter of the nervous centres. 
There are two forms of glioma, the one hard, the other soft. The former 
has a considerable anatomical resemblance to simply sclerosed tissue; the 
latter, which is the more common, blends on the one hand with myxoma, 
on the other with small round-celled sarcoma. Gliomatous tumors of 
minute size sometimes stud the ependyma of the ventricles. They are 
usually found, however, in the substance of the hemispheres, more espe- 
cially in their posterior lobes and in their upper and lateral parts. But 
they may be met with elsewhere in the nervous centres, and even in the 
spinal cord. They are for the most part solitary, of slow growth, and apt 



p 



MORBID GROWTHS. 919 

to attain a large size, as that of the fist, or even of the foetal head. Owing 
to the great vascularity of the softer forms of tumor, they are liable to 
j attacks of congestion, and to more or less abundant internal hemorrhage. 

c. Sarcomatous tumors occur both in the dura mater of the brain and 
cord, and in the substance of these centres. They vary widely in their 
microscopical structure, and in their aspect and rapidity of growth. But 

' they may be divided roughly into two forms — hard and soft. The former 
I has some resemblance to fibroma, the latter is usually more or less trans- 
i lucent, white or gray, vascular, and, from its general resemblance to brain- 
j substance, has been termed in other organs than the brain, cerebriform. 
j Sarcoma of the cerebral dura mater generally occurs at the base, in the 
. neighborhood of the sella turcica or petrous bones ; that of the theca ver- 
I tebralis affects no special seat. Sarcoma originating in the nervous tissue 
is usually of the soft form and solitary, and often grows to a large size. In 
I the brain its usual seats are, not the hemispheres, but the optic thalami, 
j corpora striata, corpora quadrigemina, pons, cerebral peduncles, and cere- 
bellum. It is only occasionally met with in the substance of the cord. Sar- 
coma originating in the nervous centres is seldom, if ever, malignant ; the 
solitary tumors, therefore, which have just been considered, are not asso- 
ciated with the presence of similar tumors in other parts. On the other 
hand, it must not be forgotten that malignant sarcomas (melanotic and 
other) of other organs are apt to be attended with multiple secondary tumors 
in the substance of the brain. Primary sarcoma of the brain is mostly a 
disease of early childhood. 

d. Carcinoma of the nervous centres, and of the parts about them, was 
formerly believed to be of common occurrence ; but by all authors up to a 
recent date, sarcoma, glioma, and probably other forms of tumors, were all 
regarded as varieties of it. Carcinoma, in the restricted sense of the term, 
originates rarely, if ever, in the brain or cord, and not often in the bones 
and soft parts immediately surrounding them. Frequently, however, dur- 
ing the period of generalization, it involves all these parts, and hence scir- 
rhous, encephaloid, and melanotic tumors are not uncommon as secondary 
occurrences in the brain or cord, and in the membranous and bony pari- 
etes of these organs. Cancerous tumors, therefore, are generally mul- 
tiple, and seldom reach a large size. Carcinoma of the skull, vertebras, 
or periosteum of these parts, is apt in its progress to reach the surface of 
the brain or cord, and to involve these organs either by pressure or by 
direct extension ; it is especially apt, moreover, to constrict the bony 
channels by which the nerves escape, to implicate the nerves, and finally 
to destroy them. 

4. Entozoa The only entozoa which infest the brain of man are the 

cysticercus cellulosse and the hydatid. 

a. Although a considerable number of cases of cysticerci of the nervous 
centres are on record, they are met with very rarely. The cysts, which are 
of the size of a pea or horse-bean, vary in number from one or two to a 
hundred or more, and they occupy either the subarachnoid tissue, the cho- 
roid plexuses, or the nervous parenchyma. In the last case, they are most 
common in the cerebral hemispheres ; but they have been met with in the 
cerebellum, medulla oblongata, and other parts. 

b. Hydatids of the brain are rare. They are generally solitary, but a 
couple or more have been found in the same case. They are almost always 
barren. Their size varies ; but they not unfrequently attain a couple of 
inches in diameter before they cause death, and may be much larger. 



920 



DISEASES OF THE NERVOUS SYSTEM. 



They generally occur in the substance of the cerebral hemispheres, but 
have been found in the cerebellum, and elsewhere in the nervous paren- 
chyma. They also affect the meninges, and have been discovered in the 
lateral ventricles, and in the subarachnoid tissue of the cord. They seldom 
cause inflammatory changes in the surrounding parts, or other mischief 
than that arising from simple pressure. Neither do they appear ever to 
become the seat of suppuration. Hydatids of the brain are not unfre- 
quently associated with hydatids of the liver or other organs. They are 
said to occur chiefly in persons between ten and twenty years of age. 

5. Aneurisms of the arteries at the base of the brain — We speak of 
these now only as tumors, and because, from their bulk and situation, they 
are exceedingly liable to interfere with the functions of important parts. 
They arise chiefly in the internal carotid arteries and their middle menin- 
geal branches, and in the basilar; but they may also be found in other 
vessels, such as the anterior and posterior cerebrals, the anterior and pos- 
terior communicating branches, and at the bifurcation of the basilar. An 
occasional seat is that portion of the internal carotid which lies within the 
cavernous sinus. They usually vary in size from that of a pea to that of 
a marble, but have been met with as large as a hen's egg. From their 
position they are liable to compress some of the nerves at the base of the 
brain, and to indent the surface of the brain itself. They usually occur 
in persons over forty, but they have been met with even at the age of 
puberty. Males are more liable to them than females. 

Symptoms and progress 1. Brain. The symptoms referable to 

tumors involving the brain present the greatest variety : a statement which 
is not likely to be disputed when one takes into consideration the various 
circumstances under which tumors arise, the different proclivities of differ- 
ent tumors, and the wide range of functionally distinct parts of the surface 
or substance of the brain which they may implicate. It is impossible, in- 
deed, to draw up any scheme of symptoms generally applicable to cases of 
the kind ; and we propose, therefore, to consider seriatim the more im- 
portant symptoms which the presence of cerebral tumors may induce. 

Vertigo is generally present at some period or other. Sometimes it is 
the first symptom of which the patient complains, and often it is the most 
constant. 

Headache is for the most part a prominent symptom. In some instances 
it is one of the earliest, in association with vertigo and occasional vomiting. 
It is often persistent, but liable to exacerbations, and sometimes only comes 
on at irregular intervals. It may be little complained of, or even be wholly 
absent. It varies in character : is sometimes a sense of constriction or 
pressure, sometimes a feeling as though the head would burst, sometimes 
shooting, aching, or boring. It is referred to different parts in different 
cases : sometimes affects the vertex, forehead, or occiput mainly ; some- 
times shoots through the ears or temples — in the latter case probably in- 
volving the eyeballs, and associated with more or less intolerance of light. 
The situation of the pain is no sure guide to the seat of disease ; never- 
theless pain referred to the occiput and back of the neck is not unfre- 
quently connected with disease in the posterior fossa of the skull. 

Vomiting is a common symptom of many cerebral diseases, and is often 
an early indication of the presence of cerebral tumors. Indeed, it is well 
known, especially in reference to the tubercular tumors of children, that 
unaccountable vomiting is often the first warning of the affection which is 
in progress. The sickness often comes on at irregular intervals without 



MORBID GROWTHS. 



021 



obvious cause, is not unfrequently attended with nausea or loss of appetite, 
and is generally associated with constipation. It may continue on and off 
during the whole of the patient's illness, but is mainly a symptom of the 
earlier stages. 

Slowness of pulse, with more or less irregularity, is of frequent occur- 
rence, more especially during the period of invasion ; subsequently also 
the same condition of pulse may prevail. But on the other hand it is then 
often of normal rate, or increased in frequency. 

Hemiplegia and Hemiancesthesia — Hemiplegia is no doubt entirely 
absent in a large number of cases, and when present usually conies on in- 
sidiously during the latter stages. There is, however, great variety as 
regards this symptom. In some instances almost the first indication of 
disease is an apoplectic or epileptiform fit followed by hemiplegia. In 
some the attack of hemiplegia comes on suddenly in the course of other 
symptoms. And in either of these cases more or less complete recovery 
from the paralytic phenomena may ensue, to be followed by a relapse or 
by a series of recoveries and relapses. The hemiplegia generally follows 
the rule of ordinary hemiplegia in the fact that the arm is more affected 
than the leg, and the lower distribution of the seventh nerve than the 
other motor nerves of the face. But occasionally the paralysis is slight or 
limited, and reveals itself only in the face or arm. It may or may not be 
associated with numbness, tingling, or anaesthesia of the paralyzed parts, 
or with hyperesthesia, tenderness, or pain. Rigidity and contraction of 
the affected limbs may supervene. 

Local paralyses are very common, sometimes in association with hemi- 
plegia, sometimes independently of it. They are generally due, not as 
hemiplegia or hemianaesthesia is to disease involving the opposite corpus 
striatum, optic thalamus, or cerebral hemisphere, but to direct implication 
by pressure or by involvement in the morbid process of the nuclei of origin 
of the affected nerves, or of the nerves themselves. If, therefore, they be 
due to the same mass that causes hemiplegia, they occur on the opposite 
side of the body to the hemiplegia. But more tumors than one are not 
unfrequently present, and tumors of the crura cerebri, pons, or medulla, 
or growths in the neighborhood of the circle of Willis, may readily involve 
directly several nerves of either side, even when causing at the same time 
distinct hemiplegic phenomena. In some cases there is paralysis of one 
or both external recti, leading to single or double internal squint; in some, 
paralysis of the whole or a part of one of the third nerves, involving ptosis, 
paralysis perhaps of the internal rectus and an outward squint; in some 
the portio dura suffers, and Bell's paralysis is the consequence, probably 
associated with paralysis of the corresponding arch of the fauces ; in some 
the hypoglossal becomes implicated. It is important in reference to these 
local paralyses to bear in mind that, contrary to what occurs in ordinary 
hemiplegia, the faradic contractility of the affected muscles rapidly disap 
pears, and acute wasting is apt to ensue. 

Implication of sensory nerves. — The fifth nerve occasionally suffers, 
either generally or in some of its branches ; in some instances intense 
burning or neuralgic pains arise, in some tingling, numbness, or absolute 
anaesthesia. In the last case the surface of the eye, among other parts, 
becomes insensible, and consequently unconscious of irritation and liable 
to inflame. Sometimes from implication of one or both olfactory nerves, 
or one or both gustatory nerves, the sense of smell or taste is lost on one 
or both sides. As regards the ears, there is not unfrequently more or less 



922 



DISEASES OF THE NERVOUS SYSTEM. 



deafness, with buzzing, rushing, or singing noises; and absolute deafness 
on one side may ensue. The most interesting and important complications, 
however, are those which involve the visual properties of the eye. We 
have alluded to the fact of the occasional occurrence of double vision and 
of intolerance of light. But, besides these phenomena, we often meet with 
more or less obscurity of vision, which may go on to complete blindness, 
in one or both eyes ; hemiopia, the field of vision being eclipsed in the 
identical halves of both retinae; the appearance of muscae ; and other visual 
derangements. The presence of cerebral tumors is, moreover, almost 
always associated with optic neuritis, or that form of it to which the name 
of ' choked disk' has been given, and which may after a time result in 
more or less atrophy of the optic disk. The same rule applies to paralyses 
of individual sensory nerves as to paralyses of individual motor nerves : 
they are usually due to direct implication of the nerves or of their nuclei, 
and are observed therefore on the same side of the face as the cerebral 
tumor which causes them. The question whether they be dependent on 
local causes or on diseases of the nervous centres above their nuclei can, 
in doubtful cases, generally be determined by the fact that in the former 
case reflex phenomena cease, in the latter they may be readily excited (M. 
Jaccoud). If, for example, the disease causing blindness be in the optic 
nerve, the pupil will be dilated, and will remain dilated when exposed to 
light, while, if it be situated above the corpora quadrigemina, the patient, 
though equally blind, will have free action of the pupil under the influence 
of the ordinary stimuli. 

These various local sensory and motor affections may come on at any 
period of the disease ; they are liable to appear and disappear before they 
become permanent ; and they tend to increase in degree and in number 
with the advance of the disease. 

Convulsions and spasms These constitute some of the most striking 

phenomena of cerebral tumors. They may be tonic or clonic, limited to 
the distribution of a single motor nerve, or implicating a group of muscles, 
a limb, the head and neck, or one side of the body. They may come on 
rarely and at distant intervals, or in frequent daily paroxysms, or may be 
almost continuous. And in either case they are apt to disappear wholly 
for a time, or to cease altogether. They are often distinctly epileptiform 
in character ; but, unlike true epilepsy, are often unattended with loss of 
consciousness ; or loss of consciousness comes on in the course of the attack 
instead of at the beginning. It is in cases of this kind, rather than in 
cases of simple paralysis, that, as Dr. Hughlings Jackson has shown, the 
seat and distribution of the peripheral phenomena point to the implication 
of definite cerebral areae. 

Intellectual and emotional disorders present great variety. In some 
cases one of the earliest indications of cerebral tumor is the occurrence of 
attacks, sometimes momentary, of incoherence, delirium, failure of speech, 
or loss of consciousness, associated or not with some partial convulsive 
movement or paralysis, or of attacks which may exactly simulate hysterical 
fits, or apoplectic seizures. On the other hand, these may be delayed until 
a late period of the disease, and may occur only as the immediate precur- 
sors of death. Sometimes they come on at long and irregular inter- 
vals ; sometimes they are very frequent, occurring many times a day, and 
even in long-continued sequences. In a large proportion of cases the 
patient suffers from gradually increasing failure of memory and hebetude : 
he becomes aphasic, or incoherent, or fatuous, and under such circum- 



MORBID GROWTHS. 



923 



stances possibly loses, or fails to exert, control over his evacuations ; or he 
gets delirious or maniacal ; and associated with some of these mental de- 
rangements, we not unfrequently find him either given to boisterous 
laughter, or low-spirited and apt to cry. 

Obstruction of venous sinuses — Cerebral tumors occasionally cause 
obstruction either of the cavernous sinus or of the sinuses between this 
and the internal jugular vein ; and, as a consequence, the veins of the 
eyelids and of the corresponding side of the forehead become more or less 
obviously distended. Similar dilatation of veins sometimes occurs in these 
cases, even when no obvious obstruction is present. 

Lastly, it may be pointed out that bed-sores are often developed sooner 
or later — occasionally early in connection with the occurrence of irritative 
or inflammatory processes ; more frequently late, when the patient is bed- 
ridden, paralyzed, and fatuous. 

We repeat that the symptoms due to cerebral tumors display remarkable 
diversity ; nevertheless, careful attention to all the phenomena of the case 
will generally allow of a fairly accurate diagnosis being made. The onset 
of the disease may be gradual or sudden ; and the symptoms which attend 
it may be of the most varied kind. The subsequent progress of the case 
is equally uncertain : sometimes the symptoms increase progressively and 
rapidly until death takes place ; sometimes, and indeed in the great ma- 
jority of cases, the patient is liable to remissions, or intervals of apparent 
restoration to health. But always such remissions become less and less 
marked with the advance of the disease, and at length continuous illness 
is established. The duration of life from the first development of symp- 
toms varies largely ; sometimes the patient sinks at the end of a few weeks ; 
sometimes death is delayed for several years. But the commencement of 
symptoms cannot always be determined — especially when the cerebral 
tumors complicate other diseases. The causes of death are various. In 
some cases the patient sinks from innutrition and the formation of bed- 
sores ; in some he is carried off in an attack of convulsions ; in most, 
death is ushered in by coma. 

It is not always possible to distinguish the symptoms of cerebral tumors 
from those caused by other affections of the same parts. Nor is this sur- 
prising, when we bear in mind : that many other diseases attack districts 
of the brain which tumors also affect, and that these as well as tumors are 
liable to be attended with swelling, inflammation, and softening of sur- 
rounding parts, and to produce both general and local symptoms. Among 
the affections here referred to are apoplectic effusions, embolic softenings, 
abscesses of the brain, and chronic diseases of the dura mater. 

The determination of the site of a tumor must rest upon a consideration 
of the various details of the paralytic and other phenomena which the pa- 
tient presents ; and especially we may here be guided by our anatomical and 
physiological knowledge, and the ascertained facts of cerebral localization. 
In many cases we may come to a fairly accurate conclusion on these points. 
But it must not be forgotten that insuperable difficulties are often presented 
by the fact, either that tumors are multiple, or that they occupy some 
tract within the hemispheres, or at their surface, lesions of which are not 
necessarily attended with hemiplegia or any specific nerve-phenomena. 

Our recognition of the nature of a tumor must depend partly on our 
knowledge of the circumstances under which different growths are apt to 
arise, partly on our knowledge of the parts of the brain which they are 
severally most prone to affect, and partly on the duration of the disease. 



924 



DISEASES OP THE NERVOUS SYSTEM. 



Tubercle occurs chiefly in children ; the cerebral phenomena due to its 
presence are often remarkably slow in their evolution ; and the disease is 
generally associated with tubercular disease elsewhere. Moreover, symp- 
toms of tubercular meningitis are apt to supervene. Syphilitic tumors 
occur in adults who have usually either a distinct history of having con- 
tracted a chancre, or obvious traces of constitutional syphilis. They have, 
moreover, a remarkable tendency to affect the under part of the brain, 
and to involve the nerves there situated ; to cause cephalalgia, defect or 
loss of smell, hemiopia, paralysis of oculo-motor nerves, deafness, paralysis 
of the portio dura, bulbar palsy, and above all, perhaps, trigeminal neu- 
ralgia or paralysis, and, in connection with these, the nutritive lesions, 
which have already been described. Further, it must not be forgotten 
that syphilitic patients are (even in the secondary period) liable to have 
sudden thrombotic occlusion of cerebral arteries, and symptoms identical 
with those attending embolism. Secondary malignant growths would be 
suspected if the patient were suffering also from a mediastinal tumor, or 
some form of malignant disease involving the skin, bones, mamma, uterus, 
or other organs. The presence of hydatids might be surmised if there 
were a total absence of all constitutional symptoms or taint and of all indi- 
cations of local inflammation or softening, if moreover the patient were 
young, and especially if an hydatid tumor were detected in the liver or 
some other accessible organ. The symptoms due to aneurisms are gene- 
rally much more obscure than from the position of the tumors might be 
supposed. Indeed, their presence is often not suspected until their rupture 
causes apoplectic phenomena and death. 

2. Spinal cord Tumors involving the spinal cord, its membranes, or 

the nerves which spring from the cord, cause symptoms due partly to the 
compression or destruction which they effect upon the substance of the 
cord, partly to involvement of the nerves, partly to local conditions of 
inflammation and the like. 

a. Those which originate in the substance of the cord are attended with 
much the same symptoms as compression of the cord connected with ver- 
tebral caries. They cause more or less complete paraplegia in the parts 
which derive their innervation from the portion of cord below ; and the 
distribution and character of the paralysis will necessarily vary according 
as the tumor is situated higher or lower in the cord, and according to the 
tract which it primarily involves, and its horizontal extension. There are 
some points, however, in regard to these tumors, which it is well to re- 
member : their presence is rarely, if ever, attended with either central or 
peripheral pain ; they originate mainly in the gray matter, and hence both 
sensation and motion are as a rule early affected ; they commonly involve 
one side of the cord or some other limited portion of the cord, in the first 
instance, and hence induce irregular or cross paralysis, so that during the 
earlier period of their development there is very likely to be motor paralysis 
on the side of the lesion, and anesthesia on the opposite side ; and the 
progress of the paraplegic symptoms is liable to remarkable remissions. It 
may be added : that, owing to certain peculiarities as to their primary site, 
it is possible that their first symptoms may simulate those of locomotor 
ataxy or those due to lateral sclerosis ; that they tend ultimately to pro- 
duce absolute paraplegia; and that, wheresoever originating, they are 
liable to be followed by ascending and descending degenerative changes, 
and by spasms and contractions of the affected muscles, with more or less 
rapid wasting of some of them. 



MORBID GROWTHS. 



925 



b. Tumors taking their origin in the meninges of the cord are apt at a 
very early period to implicate the sensory or motor roots of the nerves 

f which are in relation with them. Hence arise (and sometimes before any 
paraplegic symptoms are developed) twitchings of certain muscles, fol- 
lowed by paresis, paralysis, and rapid wasting, and burning or quasi-neu- 
ralgic pains referred to the peripheral distribution of certain nerves (it 
may be in the first instance to a single spot) — pains which are subject 
to great variations, are often exceedingly intense, and are occasionally 
attended by cutaneous eruptions. The paraplegic symptoms of such cases 
are usually undistinguishable from those accompanying vertebral caries, 
and are (at all events in the first instance) due to compression of the cord 
alone. It is obvious that the distribution of the paralytic phenomena, and 
the order of their sequence, must depend largely on the position of the 
tumor and the direction in which pressure on the cord is applied. [Reflex 
excitability is usually very much increased in the myelitis which is caused 
by the pressure of a tumor. According to Erb, a light tap on a bone or even 
a fascia is often sufficient to excite contraction of the muscles connected 
with it, and powerful pressure of the patella downwards will produce reflex 
clonus of the quadriceps. In other forms of myelitis the degree to which 
this symptom exists depends very much upon the stage of the inflammation 
and the extent of the cord involved.] 

c. Tumors which are primarily developed in the tissues external to the 
membranes, more especially therefore aneurisms and malignant growths, 
usually involve the sensory and motor nerves in the neighborhood of their 
origin long before they involve the cord itself. These, far more even than 
tumors originating in the meninges, are thus apt to induce severe sensory 
and motor troubles of limited distribution. The pain which they provoke 
is burning, wrenching, or crushing, constant, but liable to frequent exacer- 
bations, which are often quite beyond endurance, and during which the 
patient grinds his teeth, groans, or actually shrieks. It is often attended 
with hyperesthesia of the affected surfaces, and probably followed after a 
while by circumscribed anaesthesia, and by bullous or erythematous erup- 
tions. The motor troubles are mainly paresis, and rapid wasting and 
contraction, of certain groups of muscles. The above phenomena occur 
with special intensity in cases of carcinoma involving the bodies of the 
vertebrae, owing partly to the tendency of the affected bodies to collapse, 
partly to the tendency to direct implication of the nerves. They are apt, 
moreover, not only to be exceedingly acute, but to have a comparatively 
wide distribution. Symptoms due to compression of the cord come on 
(if they come on at all) at a later period. 

Assuming the presence of a tumor, its nature can only be determined 
in certain rare cases. If tubercle be ascertained to exist in other organs, 
we have some reason to suspect that associated paraplegic symptoms (if not 
due to vertebral caries) are due to a tubercular mass in the substance of 
the cord. If paraplegic symptoms come on during the reign of constitu- 
tional syphilis, we may have in that association a clue to the nature of 
their cause. If they be preceded by agonizing pain, such as has been above 
described, we have grounds to suspect the presence of some tumor involv- 
ing the vertebrae ; and if they come on in the course of mammary or ab- 
dominal cancer, and especially if we find the spine presenting some local- 
ized obtuse bend in the neighborhood of the point from which pain radiates 
and paraplegic symptoms begin, we have confirmatory evidence of the 
strongest kind. 



926 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — The treatment of tumors, whether of the brain or cord, 
must be for the most part simply palliative. We must endeavor to relieve 
sickness by some of the various methods which are usually had recourse 
to for that purpose ; to alleviate pain, either by the application of cooling 
lotions, ice, aconite, belladonna, or other sedatives, to the seat of pain, or 
by the internal exhibition of sedatives or narcotics, especially Indian hemp 
or opium ; to calm convulsions or mental excitement by suitable remedies ; 
to promote appetite ; to keep the bowels free, and the patient clean ; to 
prevent the formation of bed-sores ; and generally to relieve symptoms as 
they arise. There are certain cases, however, in which treatment is of 
real value, either in arresting the progress of a tumor or in causing its 
removal. Tubercular masses are often of exceedingly slow growth, and 
may, in fact, remain quiescent for months or years. If we have reason to 
suspect the existence of such tumors, it is of course important to have re- 
course to iron, cod-liver oil, and other drugs and modes of treatment ser- 
viceable in tuberculosis. Tumors of syphilitic origin may often, if attacked 
early, be so far influenced by treatment that the patient becomes practically 
restored to health ; and, even if complete restoration be not effected, great 
and permanent amendment may ensue. Iodide of potassium and mercury 
are the drugs specially indicated in these cases. 



IX. CEREBRAL AND SPINAL HEMORRHAGE. {Apoplexy.) 

Causation. — Excepting those forms of hemorrhage (which have little 
clinical interest) occurring in the course of purpura, smallpox, and other 
specific disorders, and due to an abnormal condition of the blood, all 
hemorrhages within the skull or spinal canal are consequent on the rup- 
ture of bloodvessels. Rupture due to violence, as for example to blows 
on the head or spine, or to fracture of these parts, may of course occur 
at any age. Idiopathic hemorrhage, however, although it occasionally 
arises below the age of twenty, becomes common only after forty; from 
which time onwards its frequency in relation to the number of persons 
living at each successive lustrum rapidly increases. Old age, therefore, 
has great influence in its causation. But there are certain other conditions 
which are of more direct importance than even old age : these are the 
presence of chronic Bright's disease, and that of degenerative affections 
of the arterial system. It is more common in men than in women. 

Morbid anatomy. — Hemorrhage may occur either between the dura 
mater and the bone, within the cavity of the arachnoid, in the subarach- 
noid space, in the nervous substance, or, lastly, in the ventricles. 

1. Meninges. — Effusion of blood between the cranium and dura mater 
is not uncommon in adults, especially as the consequence of blows on the 
head or fractures of the skull, and is usually immediately referable to 
laceration of the middle meningeal artery. The ex'travasated blood sepa- 
rates the dura mater from the bone in some limited area, and forms a con- 
vex protuberance, which displaces the cerebral surface in relation with it. 
If the patient survive, the blood undergoes those changes which are com- 
mon to all such extravasations, and, after a while, becomes absorbed. 
Hemorrhage external to the theca vertebralis is also mostly due to mechani- 



CEREBRAL AND SPINAL HEMORRHAGE. 



927 



cal violence. It may, however, result from the rupture of an aortic aneu- 
rism. 

Hemorrhagic accumulation in the cavity of the arachnoid is always ref- 
erable to escape of blood either from the dura mater or from the subarach- 
noid tissue. If the dura mater be its source, it may be either a direct 
consequence of mechanical violence, or derived from a patch of pachy- 
meningitis, with hemorrhage between its laminae. If the subarachnoid 
tissue be its source, it may be due to any one of the causes, to be presently 
discussed, of effusion of blood into that part. The arachnoidean cavity 
appears to be a frequent seat of effusion of blood in new-born children, 
probably from violence in the process of being born. Blood escaping into 
this cavity readily diffuses itself throughout its whole extent. Here, as in 
other cases, if the patient live, the blood for the most part undergoes gradual 
absorption ; occasionally, however, it gets converted after a time into a 
thin-walled cyst, full of limpid serous fluid, with little or no tendency to 
undergo further change. 

Hemorrhage into the subarachnoid tissue is frequently due to the rup- 
ture of an aneurism of one of the arteries at the base of the brain. It is 
generally then very abundant, and distends primarily all the lax tissue 
which abounds in this locality; encircling the vessels and nerves and con- 
cealing them from view, together with the surface of the crura cerebri, 
pons, and adjoining part of the medulla oblongata; and extending thence 
into the laminae of the velum interpositum and the corresponding dupli- 
catures connected with the fourth ventricle*, along the fissures of Sylvius, 
and, according to circumstances, over more or less of the surface of the 
cerebral hemispheres and lobes of the cerebellum. Sometimes the blood 
escapes by laceration from a hemorrhagic cavity in the substance of the 
brain either into the ventricles or on to the surface. This accident is not 
uncommon in the neighborhood of the island of Reil, in which case the 
centre of the meningeal extravasation will be the recess at the bottom of 
which the island is situated ; it is apt also to occur when blood is effused 
into the pons or crus cerebri. Another cause of subarachnoid hemorrhage 
is punctiform extravasation, or extravasation from injury to the surface of 
the brain, as is caused by contre-coup. Subarachnoid hemorrhage is occa- 
sionally also observed in connection with the cord. 

2. Brain Hemorrhage into the substance of the brain, especially if it 

be into certain parts of the cortex, may be due to laceration from violence; 
but it is a far more common consequence of the rupture of diseased vessels 
or of the miliary aneurism which Charcot and Bouchard have shown to 
be frequently present mainly in the optic thalami, corpora striata, cerebral 
convolutions and pia mater, in cases of cerebral hemorrhage and in old 
people. The vessels in which rupture takes place are usually the seat of 
either fatty degeneration, calcareous deposit, or chronic arteritis, with 
hyperplasia of the corpuscles of the outer wall and perivascular sheath. 
The minute aneurisms which usually stud them vary, perhaps, from the 
size of a small pin's head downwards, but occasionally they are as large as 
a grain of wheat, or larger. The escape of blood in some instances, doubt- 
less, is from a single aneurism or vessel; but much more frequently it 
takes place simultaneously from many lacerations occurring within a cir- 
cumscribed area. In some cases the hemorrhage is mainly from capillaries ; 
it is then apt to be spotty, and a careful examination will probably reveal 
in the centre of each spot a capillary vessel, with its lymphatic sheath 
distended with blood — a capillary dissecting aneurism, in fact. In other 



928 



DISEASES OF THE NERVOUS SYSTEM. 



cases, and more especially in those in which the effusion is considerable 
and in mass, the presence of miliary aneurisms, and even the ruptured 
aneurisms, can generally be easily recognized. But here also the rupture 
is first into the perivascular sheath, so that a dissecting aneurism precedes 
the actual escape of blood into the surrounding nervous tissue. The 
quantity of blood which may be poured out into the brain-substance varies, 
roughly speaking, from a few minims to several ounces. Groups of minute 
or capillary extravasations are occasionally alone present; and generally, 
when a large hemorrhagic cavity exists, the tissues around are studded 
more or less abundantly with similar small hemorrhagic spots. The 
escaping blood necessarily tears up the brain-substance ; and thus, when 
its amount is large, a very irregular cavity is produced, the interior of 
which is occupied by blood mingled with the debris of the broken-down 
nervous tissue, while the margins are formed by the irregular interdigi- 
tation of the lacerated brain-substance and of the peripheral portions of 
the clot. 

The extravasated blood speedily coagulates, and if the post-mortem 
examination be performed shortly after its effusion, will be found to pre- 
sent the ordinary characters of recent clot. If, however, the patient sur- 
vive, changes gradually ensue in it and in the brain-substance around. 
The irregularities of the cavity get smoothed away, its form becomes more 
rounded, and its margins denser and better defined. The clot contracts, 
grows drier and more friable, assumes a brownish or rusty tint, and gradu- 
ally undergoes more or less complete absorption : the final result being the 
formation either of a cicatrix (which can only happen if the effusion were 
very small), or, as far more commonly occurs, of a cyst traversed by deli- 
cate processes of connective tissue, occupied by a thin serous or milky 
fluid, and studded as to its parietes with pigmentary particles and crystals 
of hsematoidine. The time required for the total disappearance of a clot 
depends upon its size : a small one may be absorbed within a week or two, 
a large one within six weeks. 

The effects of clots on the surrounding brain-tissue must not be omitted. 
In the first place, they always cause more or less displacement and pres- 
sure, and, if large, flattening of the convolutions, obliteration of the sulci, 
and displacement of subarachnoid fluid from a greater or less extent of the 
surface which overlies them. In the second place, the surrounding tissue, 
for some little distance, always becomes yellow from imbibition of the 
coloring matter of the clot, cedematous, and more or less softened. In 
the third place, they are very apt to set up inflammatory mischief in the 
parts which are in their immediate vicinity. And, lastly, at a later period, 
descending atrophic changes, which have already been described, are liable 
to supervene. 

Hemorrhage may occur in any part of the brain ; but it takes place 
mainly in the corpus striatum, and is then generally due to laceration of 
some of the twigs of a particular branch of the internal carotid, to which 
Charcot calls special attention, and which we have already referred to. 
After the corpus striatum, the parts most likely to suffer are the optic 
thalamus and the white substance of the brain immediately external to 
these bodies. Hemorrhage occasionally also takes place in the crus cerebri, 
pons, or cerebellum, and, though much more rarely, in the medulla ob- 
longata. Large effusions may implicate the optic thalamus and corpus 
striatum at the same time, and even destroy these bodies completely. 
More frequently, perhaps, they involve the corpus striatum and external 



CEREBRAL AND SPINAL HEMORRHAGE. 



929 



capsule. They are very apt to rupture into the lateral ventricle, or, if 
they extend outwards, into the subarachnoid tissue in the neighborhood of 
the island of Keil. In the latter case, more or less abundant effusion of 
blood takes place on to the surface of the brain ; in the former case, one 
or both lateral ventricles, or the whole system of ventricles, including the 
fourth, becomes inundated with blood and sometimes enormously distended. 
Hemorrhage into the pons is not unfrequently continued thence by rup- 
ture either into the fourth ventricle or into the subarachnoid tissue below. 
It is not common for more than one extensive hemorrhage to take place 
in the brain at one time. But it is by no means uncommon to discover, 
after death, the remains of one or two or even more extravasations in addi- 
tion to the recent one which has caused death. 

Hemorrhage into the ventricles is almost always secondary to hemor- 
rhage into the brain-substance or to rupture of aneurisms at the base. 

3. Cord — Effusion of blood into the substance of the cord is very rare. 
It depends no doubt in some cases on the laceration of diseased vessels ; 
but in the great majority of cases is probably (as Charcot suggests) second- 
ary to inflammatory softening. 

Symptoms and progress. — 1. Brain. The term 'apoplexy' is so com- 
monly used to imply cerebral hemorrhage, and is on the whole so misleading 
when thus used, even if its scope be limited by the prefix ' sanguineous,' 
that it may be well to observe here that typical apoplexy — that condition 
in which the patient suddenly falls down in complete coma, with total 
abolition of motion and sensation, and of sense, with full pulse, and slow, 
stertorous breathing — is very seldom observed in cases of effusion of blood 
within the cavity of the cranium. Further, in most works, and especially 
in those of the older school, much stress is laid upon the type of body 
which is most liable to apoplexy, on the habits of life which predispose to 
it, and on the various symptoms which # were supposed for weeks, months, 
or even years, to herald the approach of the actual seizure. It is certain, 
however, that although there was some amount of truth in the observations 
which led to these generalizations — a sort of rough connection between the 
collective antecedents above hinted at and the supervention at some period 
or other of death, ushered in with an apoplectic seizure, or due to hemor- 
rhagic effusion — there is little or no direct connection between them and 
the rupture of a bloodvessel in or on the brain. 

In a large number of cases of cerebral hemorrhage the attack comes on 
suddenly and unexpectedly, although it may be freely admitted that in no 
inconsiderable proportion of them there has pre-existed, for a longer or 
shorter time, either chronic Bright's disease, or some distinct evidence 
that degenerative changes have been going on in the arterial system. In 
other cases there have been more or less distinct precursory symptoms, 
referable to local disturbance of the cerebral circulation, caused either by 
partial obstruction of some artery or by the occurrence of capillary bleed- 
ing, or it may be by the actual formation of a hemorrhagic cavity which, 
either from its smallness or from its situation, is unattended with striking 
symptoms or permanent injury. Among the symptoms here adverted to 
may be enumerated headache, vertigo, confusion of thought, failure of 
memory, drowsiness, want of sleep, irritability of temper, and the like. 
Others are bleeding from the nose and retinal hemorrhage. But the most 
important are temporary paralytic phenomena, such as numbness or tin- 
gling on one side of the body or in the arm or leg, loss of power in the 
same parts, or in one half of the tongue or face, difficulty of articulation 
59 



930 



DISEASES OF THE NERVOUS SYSTEM. 



or deglutition, and double vision. It must not, however, be assumed that 
any of these symptoms necessarily points to the occurrence of hemorrhage. 
They may equally indicate the presence of a tumor or other circumscribed 
lesion, or be connected with epilepsy or other purely functional affections 
of the brain. 

The symptoms which attend effusion of blood into the brain are very 
various both in kind and in severity. Sometimes the patient, while 
engaged in his ordinary avocations, suddenly finds that he has lost the use 
of his arm, and presently becomes hemiplegic ; sometimes while engaged 
in conversation his articulation becomes thick, and he presently discovers 
that his mouth is drawn to one side, and that an arm and leg are limp 
and weak ; sometimes the first intimation that there is anything amiss is 
the accidental discovery by the patient that one side of his body is totally 
useless when he attempts to rise from his bed in the morning, or from a 
chair in which he has been sitting quietly or dozing. In other cases the 
appearance of paralysis is attended or preceded by sudden giddiness or 
confusion of thought, or by a pain or sensation in the head which makes 
the patient cry out. In some instances he talks and acts for a few seconds 
like a drunken man. In some he suddenly becomes faint and collapsed, 
with pallid face, cold damp skin, feeble irregular pulse, and vomiting — the 
affection is ushered in indeed with an attack of syncope, during which he 
may become more or less completely insensible, but from which he often 
recovers. In exceptional cases only does the patient become at once in- 
sensible ; and then the attack is apt to commence with a convulsion. The 
last, it may be added, are for the most part cases in which blood is effused 
into the pons Varolii, or on to the surface of the brain from rupture of a 
large vessel or aneurism. 

The further progress of the disease presents the greatest variety. In 
some instances the patient's symptoms stop short at that indistinctness of 
speech or that unilateral paresis with which he was probably first seized ; 
and he remains in this condition for a few hours, a few days, or a few 
weeks. In some instances these primary symptoms become aggravated up 
to the supervention of absolute hemiplegia, with or without anaesthesia ; 
in which condition again the patient may remain for a variable time, some- 
times recovering completely sooner or later, sometimes undergoing imper- 
fect recovery, and remaining more or less feeble on the affected side, or in 
some degree inarticulate, for the remainder of his life. Not unfrequently 
headache, vertigo, impairment of intellect, or alteration of temper, not only 
is present during the continuance of the paralysis, but persists even after 
its amelioration or disappearance. Occasionally there is temporary devia- 
tion of the eyes, and even of the head and neck, towards the paralyzed 
side. In many instances more or less profound coma presently succeeds 
the symptoms of invasion. This may come on in the course of a few 
minutes, or a few hours, or a few days, even in those cases in which the 
initial symptoms are of the mildest character. It generally supervenes 
before long in those whose first symptoms are those of shock : the patient 
recovers from his faintness, perhaps to find himself hemiplegic, not im- 
probably to feel fairly well ; but by degrees drowsiness and stupor creep 
on and gradually deepen into profound coma. 

But however the coma may come on, whether it be gradual in its inva- 
sion, whether it supervenes in the course of symptoms already pointing to 
cerebral hemorrhage, or whether it become developed in all its intensity 
within a few minutes or a quarter of an hour of the first signs of illness, its 



CEREBRAL AND SPINAL HEMORRHAGE. 



931 



symptoms do not on that account present any differences. The patient 
lies-on his back insensible, with face more or less flushed, skin moist, 
pulse slow, perhaps irregular, but full and more or less hard, respirations 
slow and attended with stertor or snoring as he draws his breath in, and 
puffing of the cheeks as he exhales, and more or less depression of tem- 
perature which may continue for some hours. In the early condition of 
this, which is sometimes termed the apoplectic state, the patient is still 
perhaps capable of being roused ; when spoken to loudly he makes some 
incoherent sound, when pinched or pushed he indicates by some movement 
or gesture that he is not altogether without feeling. But soon he becomes 
utterly unconscious. In this condition many various symptoms cluster, as 
it were, around his unconsciousness. In some cases he lies on his back 
quietly as if asleep, his expression placid, his limbs apparently unaffected 
assuming a natural attitude. But frequently there is some obvious mus- 
cular affection : the limbs of one or both sides are flaccid — when raised 
falling back helplessly on the bed ; or they are rigid, and offer more or 
less resistance to the attempts to move them; or convulsive twitches or 
more powerful spasmodic movements occur from time to time either gene- 
rally or on one side of the body. There may, in fact, be simply that failure 
of the muscles to move which stupor alone involves, or there may be 
general or unilateral paralysis with or without flaccidity, rigidity or con- 
vulsive movements. In the face the same conditions may be observed ; 
sometimes the muscles are in repose ; sometimes more or less obvious 
facial palsy is observed upon one side, sometimes twitching of the muscles. 
The eyelids are generally shut. The condition of the eyes varies ; fre- 
quently the pupils are dilated, especially towards the fatal close ; some- 
times, and more especially in cases of hemorrhage into the pons, they are 
contracted ; often they are natural ; they are sometimes irregular, some- 
times insensible to light. The last are symptoms of considerable signifi- 
cance. In the early state the patient, though unable to masticate, is still 
able to swallow fluid or food placed in the back of his mouth ; when, how- 
ever, the case is going on unfavorably, the power of deglutition fails abso- 
lutely. Respiration is, as has been stated, usually slow, but it is often 
irregular, and is liable to cease completely for some seconds. Sometimes 
the patient breathes as quietly as a child. But when a fatal termination 
is impending, stertor (if it were not before present) comes on ; mucus and 
other fluids accumulate at the back of the throat and in the air-passages ; 
the breathing becomes attended with loud rattling sounds, and the respira- 
tory movements are often accelerated. The character of the pulse varies: 
at first probably it is slow, full, and hard, but it may be of natural rate, 
and present no deviation whatever from the normal ; but with the continu- 
ance of coma it is apt to increase in frequency, and may rise to 120, 140, 
or 160 in the minute. The face usually is flushed, the skin more or less 
moist ; and towards the end of life profuse sweats generally if not always 
break out. The patient has retention of urine, and loss of control over his 
alpine evacuations. Inability to swallow, accumulation of fluids in the 
fauces and air-passages, indifference of the pupils to light, failure of the 
eyelids to close when touched, extreme rapidity of pulse, and the occur- 
rence of profuse perspirations are phenomena of the gravest omen. 

In some cases the stupor of coma passes in the course of a few minutes, 
a few hours, or a few days, into that of death. But in a considerable 
number of cases the patient, after a longer or shorter time, slowly emerges 
from it, regains his consciousness more or less completely, and probably is 



932 



DISEASES OF THE NERVOUS SYSTEM. 



found to be paralyzed on one side, and to present a greater or less number 
of other indications of cerebral mischief. From this point, sometimes re- 
covery is rapid and thorough ; sometimes more or less complete hemiplegia 
continues temporarily, or, after more or less improvement, for life ; some- 
times he has hemiansesthesia as well as paralysis ; sometimes his speech 
remains indistinct ; sometimes he has more or less complete asphasia ; 
sometimes he complains of headache or giddiness ; sometimes he has loss 
of memory, failure of intelligence, or emotional perversion ; or he may be 
stupid or demented, and then not unfrequently fails to control his bowels 
or his bladder. It is obvious that the various conditions here described 
are in the main identical with those which are apt to follow hemiplegia 
coming on without insensibility; and that, in fact, but for the circum- 
stances that the supervention of coma on the whole implies either a large 
effusion of blood, or effusion into some vital part, and that coma itself 
brings with it special dangers, there is no essential difference as regards 
their subsequent progress between those cases of cerebral hemorrhage 
which are attended with coma and those which are and have been free 
from coma. 

The character of the symptoms will be determined largely by the seat 
of lesion, by the size of the clot, and by the rapidity with which the blood 
is effused. When hemorrhage occurs in the corpus striatum, or in the 
white matter or convolutions of the brain in relation with the motor tract, 
or in the crus cerebri, motor hemiplegia will almost necessarily follow, and 
will probably be more complete according as the amount of brain-substance 
destroyed or compressed is larger. If, however, the effusion take place in 
the white matter of the hemisphere, paralysis is more likely to be absent 
than if it occur lower down ; if it take place in the crus, it is probable 
that the third or fourth or some other of the nerves on the same side as 
the clot will also be implicated. Aphasia generally attends right-sided 
paralysis. Hemianesthesia alone is rarely if ever present ; but it is not 
unfrequently associated with hemiplegia, especially perhaps with hemi- 
plegia of the left side ; in which case the hemorrhage probably involves 
the optic thalamus, internal capsule, or crus. If blood primarily effused 
into the corpus striatum or other neighboring parts escape with sudden 
violence into the ventricular cavities and flood them, the pressure which is 
at once exerted on a large number of ganglia essential to life induces sud- 
den profound coma with general paralysis and flaccidity of the limbs. 
Also, if the surface of the brain be suddenly deluged with blood, profound 
coma almost immediately ensues, which is often attended with convulsions, 
but by no means necessarily with paralysis, and in some cases, especially 
if it be at the base, with inequality of pupils. When hemorrhage occurs 
into the pons, there are often convulsions, and usually sudden profound 
coma and general paralysis, attended at the commencement with contrac- 
tion of pupils ; and the case is rapidly fatal. Sometimes, however, the 
effusion here is small in amount and unsymmetrical in position, in which 
case the paralytic symptoms will probably be more or less irregularly dis- 
tributed ; there will perhaps be hemiplegia, with more or less complete im- 
plication of various sensory and motor nerves, situated either on the side 
opposite to the hemiplegia, or irregularly on both sides ; there is apt also 
to be more or less serious interference with the muscles of speech and 
deglutition — the usual symptoms, in fact, of bulbar paralysis. Hemor- 
rhage into the cerebellum is often attended with severe occipital pain, 



CEREBRAL AND SPINAL HEMORRHAGE. 



933 



vomiting, and especially with vertigo. Paralysis is for the most part 
absent, but the patient, if able to walk, staggers like a tipsy man. 

We have already pointed out that a patient who has had cerebral hemor- 
rhage, whether he has had coma from which he has emerged, or whether 
he has had a simple attack of paralysis and has attained that stage at 
which all present fear of coma has passed away, may rapidly or slowly 
recover from all his symptoms, may recover imperfectly, or may remain 
without any improvement whatever. We have not, however, referred to 
the important fact that various complications may arise in the progress of 
the case. The principal of these may be briefly considered, a. The pre- 
sence of a clot, and of the collateral oedema which always attends its 
presence, is very apt to induce at any time during the first few weeks after 
its formation some inflammation in the surrounding brain-tissue — an 
occurrence which is often indicated by more or less elevation of tempera- 
ture, rapidity of pulse, return of paralysis, drowsiness, and impairment or 
loss of control over the emunctories, and may lead to coma and death. 
b. Bed-sores are apt to form. In some instances these come on when the 
patient is bed-ridden, or has continued for some length of time in a fatu- 
ous or semi-comatose condition, just as they may come on in any other 
persons who are confined to bed and of uncleanly habits. But they are 
also apt to appear, and then mainly upon the buttock of the paralyzed side, 
from the second to the fourth day after the attack, apparently in conse- 
quence of some direct influence transmitted from the seat of lesion in the 
brain. The formation of these early bed-sores is always a bad sign, and 
almost without exception foretells an early fatal issue, c. Inflammation of 
internal organs, such as pneumonia, dysenteric ulceration, and the like, 
occasionally supervenes, d. Not unfrequently, after the second or third 
week, or later, if the limbs remain paralyzed, rigidity and contraction 
gradually ensue, associated after a while, in some cases, with wasting of 
the muscles. This rigidity is not to be confounded with the temporary 
irritative rigidity sometimes observed at the commencement of paralysis, 
but is the consequence of secondary degenerative changes in the course of 
the lateral columns of the spinalcord, and is permanent. It is observed 
by Trousseau that in those rare cases of hemiplegia in which the arm 
recovers more rapidly than the leg, the prospects of the patient are very 
gloomy; that the leg becomes stiff and painful; that imbecility comes on, 
and the patient usually dies within the year. Whatever the explanation 
of the imbecility in these cases may be, it seems pretty certain that the 
arrested recovery of the leg is sometimes due to the fact that degenerative 
disease has already commenced in the cord. e. All patients who have had 
one attack of cerebral hemorrhage are specially likely to have subsequent 
attacks ; and sometimes two or three of these occur at irregular intervals, 
previous to the fatal issue of the case, adding complexity to the patient's 
symptoms. Lastly, partly from the effect of the primary lesion, partly 
from the associated diseased state of arteries, partly from pressure, oedema, 
inflammation, or degeneration of surrounding parts, many additional 
symptoms are liable to come on — among others athetosis, epileptiform 
attacks, delirium, mania, or dementia. 

2. Cord — Hemorrhage into the arachnoid cavity or subarachnoid tissue, 
or into the substance of the cord is so rare, except as a consequence of 
injury or pre-existing disease which has already caused^ serious symptoms 
referable to the cord, that it is scarcely necessary to discuss the symptom- 
atology of these lesions. It is sufficient to say that hemorrhage around 



934 



DISEASES OF THE NERVOUS SYSTEM. 



the cord will naturally cause the symptoms of pressure — namely, more or 
less loss of voluntary motor power, associated with little or no impairment 
of sensation; and the effects Avill vary according to the seat of the effusion, 
its extent, and the degree of pressure exerted by it; and that hemorrhage 
into the substance of the cord will be attended with precisely those symp- 
toms which occur in inflammatory softening involving the whole thickness 
of the cord. 

Treatment. — When a patient is seized with sudden paralytic symptoms 
due, as we suppose, to hemorrhage, there is little to be done save to keep 
him perfectly quiet, mentally and bodily, to make him lie down with his 
head somewhat elevated, in a room of equable but not elevated tempera- 
ture, and to feed him sparingly with milk and farinaceous food. There is 
no harm, probably, even if there is no good, in giving him cooling drinks, 
and in administering medicines which are supposed to check hemorrhage. 
A powerful purgative is often given, but it is questionable whether the 
straining which attends its action is not more injurious to the patient than 
the retention of fecal matter in the bowels. If coma have come on, again 
there is little to be done beyond leaving the patient at rest. Some bleed, 
but bleeding will not benefit those who have large effusions of blood in the 
pons or ventricles, or on the surface ; and those who have large hemor- 
rhages elsewhere for the most part recover from their coma without any 
such assistance. Further, bleeding is probably quite incompetent to arrest 
cerebral hemorrhage. Nevertheless, we are inclined to believe that the 
guarded removal of blood in these cases may sometimes prove beneficial 
by diminishing pressure within the skull, or, as Sir Thomas Watson sug- 
gests, by relieving the congestion of the right side of the heart, which is 
often manifested by engorgement of the veins of the head and neck, and 
lividity of surface. At all events, a single bleeding will probably have no 
injurious effect whatever. It is customary to give powerful purgatives in 
these cases, such as a couple of drops of croton oil alone, or mixed with 
a little castor oil; and, on the whole, the practice appears to be good; pur- 
gation tends to derive (as the expression is) from the head; and in cases 
of profound coma does not induce that powerful straining which is so great 
an objection to its employment when the patient is sensible. Other meas- 
ures which may be adopted are the application of cold in the form of evap- 
orating lotions or ice to the shaven head, or of counter-irritants, such as 
mustard plasters, to the head, back of neck, and legs. During the further 
progress of paralysis following hemorrhage, the chief things to do are still 
to keep the patient quiet, and free from either mental or bodily excitement, 
to regulate his hours and employments, to keep his bowels regular, if neces- 
sary, by the use of opening medicines, to relieve all discomforts and second- 
ary affections under which he may happen to labor, to counteract, as far 
as possible, the effects of any renal or other organic disease of which he 
is the subject, and to attend very carefully to his diet. As a rule, all alco- 
holic beverages should be interdicted, or, if circumstances render their use 
necessary, should be allowed only in small quantities, and in a dilute form. 
The patient should be well nourished, but the amount of food given him 
should not exceed what is essential for his well-being. The food, more- 
over, should be wholesome and readily digestible. It is often recommended 
that the patient should be restricted to a vegetable diet and milk — a diet 
which is doubtless very appropriate if there be any chronic renal affection. 
But if his abdominal viscera be healthy, we do not see how such diet 
should have any superiority over a diet containing a fair proportion of 



OBSTRUCTION OF CEREBRAL ARTERIES. 



935 



animal food. As regards the affected limbs, friction and faradism are some- 
times efficacious, when the acute symptoms have passed away, in promoting 
the restoration of the impaired motor powers ; and when late contraction is 
occurring it may be relieved or prevented by galvanizing the contracting 
muscles and faradizing their opponents. 



X. OBSTRUCTION OF CEREBRAL ARTERIES. 

{Thrombosis. Embolism. Softening.) 

Causation and morbid anatomy We have drawn attention to the 

facts : that the group of arteries supplying the brain, although anastomosing 
freely in the circle of Willis, have no further communication with one 
another excepting by means of the capillary vessels situated at the peri- 
phery of their several areas of distribution; that the same arrangement 
holds good with respect to every branch of these arteries, clown to their 
smallest twigs ; and that hence any obstruction, however produced, whether 
in a primary or in a subordinate branch, no matter how small, puts a stop 
to the circulation of the blood in the district to which the obstructed ves- 
sel leads, and involves its degeneration and death. The same rule obviously 
does not apply with equal force when obstruction takes place in the basilar 
or either internal carotid artery below the anastomosis, since by means of 
that anastomosis blood, for the most part, finds its way readily from the 
pervious trunks to the branches of the obstructed vessel. Nevertheless, 
such obstruction, or even obstruction of the common or internal carotid in 
the neck, occasionally influences seriously the nutrition of that portion of 
the brain with which the obstructed vessel is in relation. The arteries of 
the cord, on the other hand, are small, are derived or reinforced from many 
sources, and rarely, so far as we known, become obstructed, or if obstructed, 
instrumental in the production of degenerative changes in the substance of 
the cord. 

The causes of obstruction are various, a. In many cases the arteries 
at the base of the brain, in persons advanced in life, get rigid, thick- 
walled, and the seat of atheromatous or calcareous degeneration ; and as 
a consequence of the advance of these processes it sometimes happens that 
one of the diseased vessels becomes reduced in calibre or altogether im- 
pervious, b. In a considerable number of cases, again, one of the arteries 
at the base of the brain or one of the primary branches becomes obstructed 
in a greater or lesser portion of its length by a clot or thrombus, which 
fills it, adheres to its surface, and after a while undergoes degenerative 
changes, in which also the vascular parietes probably share. The causes 
of such thrombosis are not always obvious. Occasionally it is due to the 
fact that the affected vessel leads to some diseased tract in which the 
smaller vessels are involved and obstructed ; and the coagulation of blood 
in it is therefore secondary. Sometimes, possibly, it is due to the special 
tendency which the blood appears to have in some dyscrasic conditions to 
undergo spontaneous coagulation. Sometimes it is determined by disease 
of the arterial walls, such as roughening from atheromatous or other 
chronic processes, inflammatory thickening, or syphilitic growth, c. But 
perhaps the most interesting cause of obstruction is the detachment of 



936 



DISEASES OF THE NERVOUS SYSTEM. 



granulations from diseased valves on the left side of the heart, their con- 
veyance to the arteries of the brain, and their impaction, usually at the 
point of bifurcation of an artery, or at some other spot where the vessel 
is too small to allow of their further transmission. The embolus usually 
forms the nucleus for the development of a thrombus extending to a greater 
or less distance in either direction along the channel of the obstructed 
artery. 

Obstruction of the arteries at the base from atheromatous or earthy 
degeneration is observed mainly in persons advanced in life, and espe- 
cially in those suffering from arterial disease elsewhere, or who are the 
subjects of chronic renal disease, or have led laborious or debauched lives. 
The obstruction usually occurs in one of the arteries forming the circle of 
Willis, or in one of the trunk-vessels below this anastomosis. 

Thrombosis is not uncommon in the vertebrals, the basilar, the internal 
carotids, and their several primary branches ; and, indeed, not very un- 
frequently involves two or three of these vessels one after the other at 
irregular intervals. Obstruction from thrombosis connected with arterial 
degeneration is an affection of advanced life ; as a consequence of syphilis, 
it is mainly a phenomenon of early adult life and middle age. 

Embolism is, in the great majority of cases, the consequence of rheu- 
matic inflammation of the valves of the heart ; it may, however, follow 
degenerative lesions of the same parts and the detachment of masses of 
calcareous or atheromatous matter, or of fibrinous tubercles which have 
become developed on the degenerate surfaces. Embolism may occur at 
almost any period of life, yet is certainly most common from puberty up 
to the age of forty or fifty. It almost always affects the middle cerebral 
artery in some part of its course, and usually the middle cerebral of the 
left side. 

The changes in the brain-substance which result from arterial obstruc- 
tion are (excepting when this takes place below or in the circle of Willis) 
almost accurately limited to the district which the obstructed vessel sup- 
plies. The affected region becomes opaque white, yellowish, or greenish, 
mottled with light red patches, or even minute extravasations of blood, 
and softened — often so soft as to break down readily into a pulp under the 
finger, or to admit of being washed away under the impulse of a stream 
of water. The microscopic characters which it presents depend on the 
appearance of granule-cells in greater or less abundance, on the degenera- 
tion of the nervous elements, more especially the white substance of 
Schwann, and its conversion into masses of refractive globules, and on the 
accumulation in the walls of the vessels and perivascular sheaths of more 
or less numerous fatty granules. Patches of softening from obstruction, 
especially if of small size, may, like apoplectic clots, become absorbed, 
and leave behind them a mere scar or a cavity containing serous or milky 
fluid. If of large size, they may undergo more or less diminution of bulk, 
and involve obvious shrinking of the mass of brain in which they are con- 
tained. Not unfrequently inflammatory changes go on in the brain-sub- 
stance around them. 

Symptoms and progress — The symptoms due to obstruction of one of 
the cerebral arteries so closely resemble those caused by hemorrhage that, 
if there be no appeal to other facts than those afforded by the cerebral 
symptoms which are present, it is utterly impossible in the great majority 
of cases to distinguish the one affection from the other. It is stated by 
Recamier and by Todd, and their views are supported by Trousseau and 



OBSTRUCTION OF CEREBRAL ARTERIES. 



937 



many others, that whenever hemiplegia, complete and absolute, occurs 
suddenly without loss of consciousness, it is due to softening and not to 
hemorrhage. And, in reference to this statement, we may point out that 
the mere sudden loss of function in a limited portion of brain-tissue (as 
occurs in softening) is likely to be attended with less general disturbance 
of the cerebral functions than the extravasation of blood into a similarly 
limited space, which not only destroys the tissues which it infiltrates, but, 
from its bulk, causes more or less serious pressure on surrounding parts. 
The rule may doubtless, within certain limits, be accepted as the expres- 
sion of a fact; but it is a rule to which there are frequent exceptions; for, 
in many cases of softening from arterial obstruction, the hemiplegia, if 
sudden, is not complete, and in some the attack is ushered in by loss of 
consciousness; while, on the other hand, hemorrhagic hemiplegia, as we 
know, is in a large number of cases unattended with insensibility. 

Various prodromal symptoms of cerebral softening are often enumerated ; 
but it is clear that in most of the varieties of softening now under con- 
sideration no symptoms of the kind are likely to be met with. They can 
attend neither embolism nor thrombosis. And any that may be referred 
to disease of the arterial walls are equally indicative of future hemorrhagic 
effusion. As a matter of fact, the symptoms due to. arterial obstruction 
are always sudden in their onset, and for the most part occur unexpectedly 
at a time when perhaps the patient seems to be in -perfect health. The 
seizure comes on in various ways: sometimes the patient, who is walking 
or making some exertion, or perhaps even sitting down quietly, is attacked 
with sudden vertigo, and more or less confusion of thought, and tumbles or 
throws himself forward on the ground ; sometimes he is seized with sudden 
pain in the head of such severity that he cries out ; sometimes he becomes 
suddenly faint, and occasionally this faintness is attended with a slight 
convulsion. [In some of the recorded cases the patients manifested at 
the moment of seizure great emotional disturbance, laughing or crying im- 
moderately, so that the attacks may occasionally simulate those of hysteria.] 
But, however various these initial symptoms, it is almost always discovered 
so soon as the momentary attack has passed that more or less complete 
hemiplegia is present. It is almost needless to say that the character of 
the symptoms' which present themselves and their severity must depend 
largely upon the size of the vessel obstructed and the part to which it is 
distributed; in other words (as also in hemorrhage), upon the amount of 
brain-substance which becomes incapacitated, and on its situation. Thus 
affections of the posterior cerebral lobes and of the cerebellum are always 
more obscure in their symptoms than those which involve the anterior parts 
of the brain, and more especially than those which involve its base. And 
hence it will be readily understood that obstructions arising in the course 
of the posterior cerebral and cerebellar arteries lead to less definite, if not 
less serious, consequences than obstructions in the course of the anterior 
and middle cerebrals. It is very important, however, for the purposes of 
diagnosis to refer to the exact distribution of the various intra-cranial 
vessels which has been given on a former page. And especially is it im- 
portant to bear in mind : that it is from the basilar artery that the pons 
mainly receives its vascular supply ; that the posterior cerebral artery is 
distributed not only to the posterior part of the cerebrum, but especially 
to the posterior part of the optic thalamus, and to the corpora geniculate 
and quadrigemina; and that in the great majority of cases, and certainly 
in almost all cases of embolism, the obstruction occurs in the middle cere- 



938 



DISEASES OF THE NERVOUS SYSTEM. 



bral artery or in one of its branches, and that the tract which then under- 
goes softening is the district to which this vessel is distributed, or some 
part of that district, which includes the greater portion of the corpus 
striatum, the internal capsule, the anterior half of the optic thalamus, and 
nearly the whole of the anterolateral region of the brain, inclusive of the 
island of Reil and the convolutions which surround the fissure of Sylvius. 
It is hence obvious in the case of embolism : that the main symptom which 
the patient would be expected to present is more or less complete (gener- 
ally complete) hemiplegia, not improbably associated with some degree of 
anaesthesia, and more or less profound impairment of intelligence ; and that 
if the disease occupy the left side of the brain, either marked aphasia, or 
total inability to utter articulate sounds, will be present. Other symptoms, 
however, which are not special to softening, are generally associated with 
these, namely vertigo, headache, sickness, rigidity of the affected limbs, 
loss of control over the bladder and rectum, and the like. 

The subsequent progress of cases of obstructed cerebral arteries depends 
largely upon the extent of softening and its situation. If the patch be 
small (even if it be in the distribution of the middle cerebral) recovery as 
complete as occurs after some cases of effusion of blood may be expected. 
[The same rule in regard to the order in which the different parts of the body 
regain the power of motion does not seem to obtain in the hemiplegia de- 
pending upon embolism of a cerebral artery as in that following upon apo- 
plexy, for it is not uncommon in the former case for evidences of returning 
strength to appear in the arm, while the leg continues motionless.] In 
most cases, however, recovery does not take place ; in some the patient 
improves up to a certain point ; in some he remains, so far as his mental 
and motor failures are concerned, much as he was immediately after his 
seizure. Occasionally, and especially if the case be one of thrombosis and 
not of embolism, several of the cerebral arteries, and even the main trunks 
of these vessels, may be obliterated at successive intervals, each attack 
adding its own special symptoms to those which had resulted from previous 
lesions. It remains a fact, however: that the patient rarely recovers com- 
pletely from the effects of thrombotic or embolic softening; that if he has 
become aphasic, the aphasia continues in a greater or less degree ; that 
hemiplegia for the most part persists, and is followed ere long by that form 
of contraction which results from secondary lesion of one of the lateral 
columns of the cord; and that occasionally arthritic effusion or inflamma- 
tion ensues, or wasting of muscles. Further, the intellect, already prob- 
ably impaired, is apt to fail, and the patient after a while to become bed- 
ridden and childish. It must be added that bed-sores occasionally form 
rapidly after softening, as they do after hemorrhage; and that inflamma- 
tory processes may go on around the softened patch and bring with them 
special symptoms. It follows on the whole that the prognosis in cases of 
softening is very unsatisfactory, and that even if patients survive they are 
apt to survive in a more or less maimed or wrecked condition. Death 
may occur at any period. Sometimes it comes on early, the patient dying 
from coma, bed-sores, or failure of nutrition, or from pneumonia, or some 
other such complication. Death at a later period may be consequent on 
the recurrence of apoplectic attacks or on the supervention of inflamma- 
tion around the focus of disease ; or it may be due to asthenia or intercur- 
rent disorders. 

There is for the most part extreme difficulty in determining of any case 
which comes before us whether it be one of sanguineous effusion or one of 



HYDROCEPHALUS AND H YDRORRH ACHIS. 



939 



softening from arterial obstruction. In many cases, indeed, there is nothing 
whatever to aid us in coming to a differential diagnosis. The chief points 
on which reliance must be placed are the following : — First, our knowledge 
of the relative seats of hemorrhage and of softening and of the different 
symptoms which they are hence likely to evoke. Second, the clinical his- 
tory of the patient and the state of his various organs : thus the case is 
likely to be one of embolism if there be heart-disease present, or if there 
be a history of his having had former cardiac mischief, or even if he have 
had an attack of acute rheumatism ; it is not unlikely to be one of throm- 
bosis if the patient have had a chancre, or if he be suffering, or present 
traces of having suffered, from the secondary or later symptoms of syphilis ; 
it is almost certain to be hemorrhagic if we discover the presence of albu- 
minuria or chronic.renal disease, arterial degeneration, or hemorrhage into 
the retinae. And, third, the age of the patient — cerebral hemorrhage 
being on the whole a disease of advanced life, embolism occurring indif- 
ferently at all ages from puberty upwards. We need scarcely repeat that 
the occurrence of sudden and complete hemiplegia without loss of con- 
sciousness and without premonitory symptoms points strongly to arterial 
plugging, while the gradual development of symptoms culminating in 
hemiplegia and coma is strikingly characteristic of cerebral hemorrhage. 

Treatment It is needless to lay down any specific rules of treatment. 

We cannot reopen an obstructed artery ; we cannot hope that the area to 
which it leads shall be fed by collateral channels. The softened part re- 
mains necrosed, and the best thing that can happen is that it shall shrink 
into an inert mass or undergo absorption. It may, however, during this 
process induce inflammatory mischief in the parts around. This contin- 
gency should be guarded against as much as possible. For this and vari- 
ous other reasons, the patient should be kept quiet and cleanly, his bowels 
should not be allowed to become constipated, and his food should be nutri- 
tious, but easy of digestion, and not too abundant. But, indeed, the same 
general treatment is applicable to these cases as to cases of paralysis after 
hemorrhage, and need not be more particularly considered. 



XI. HYDROCEPHALUS AND HYDRORRHACHIS. 

( Cerebral and Spinal Dropsy?) 

Causation and morbid anatomy Dropsical accumulations in the cavi- 
ties connected with the brain and cord are not uncommon, their chief seats 
being the subarachnoid space and the ventricles. A relative excess of 
subarachnoid fluid, which has been mistaken for dropsy, is generally ob- 
served in connection with the shrunken brains of old persons and of those 
who die demented or fatuous, or the victims of certain other chronic forms 
of insanity. Whenever any portion of the brain, whether from congenital 
defect or as a consequence of disease, wastes, the space which it formerly 
filled becomes occupied either by an excess of subarachnoid fluid or by fluid 
accumulated in a local dilatation of one of the ventricles. Further, effu- 
sion of serum attends the progress of many morbid conditions, such as in- 
flammation, morbid growth, and softening : thus in some cases of meningeal 
inflammation, inflammatory products with excess of fluid accumulate in 



940 



DISEASES OF THE NERVOUS SYSTEM. 



the subarachnoid space ; in some cases the substance of the brain becomes 
wetter or more succulent than natural, or serous infiltration (collateral 
oedema) occurs in the vicinity of foci of disease ; and in some cases (and 
these are the most frequent and important) the lateral ventricles, the third 
ventricle, or the fourth ventricle, or all of them together, get largely dis- 
tended with fluid. In the last series of cases the accumulation of fluid in 
one situation is balanced by its removal from other situations ; and hence, 
as a rule, excess of fluid on the surface is attended with comparative ab- 
sence of fluid from the ventricles ; and dropsy of the ventricles or sub- 
stance of the brain causes flattening of the convolutions, obliteration of the 
sulci, and dryness of the subarachnoid tissue. Dropsical effusion plays a 
more or less important part in the production of symptoms in the cases 
which it complicates ; but by far the most important, in this respect, is the 
intra-ventricular dropsy, which is so commonly associated with the pres- 
ence of tubercles or other tumors of the brain, or of meningeal inflamma- 
tion, and Avhich occasionally arises (both in children and in adults) as an 
independent malady. This is often referred either to compression or ob- 
struction of the venze Galeni, or to closure of the communication with the 
subarachnoid tissue which exists at the posterior extremity of the fourth 
ventricle. 

The most important and striking forms of dropsy are congenital or come 
on without obvious cause shortly after birth, sometimes associated with 
malformation, sometimes independently of it. 

1. Among the former of these classes must be included: in connection 
with the brain, hydro-meningocele and hydrencephalocele ; in connection 
with the cord, spina bifida, a. In hydro-meningocele and hydrencephalo- 
cele, a congenital perforation is present, either in the occipital bone (which 
is most common), or in some other part of the vault of the cranium ; through 
which protrudes, in the form of a tumor, either the membranes of the brain 
alone, with a circumscribed accumulation of serum (hydro-meningocele), 
or a portion of brain nipped off, as it were, from the rest, and usually con- 
taining within it a dilated dropsical diverticulum from one of the ventricles 
(hydrencephalocele). 

b. Spina bifida generally occurs in the sacral or lumbo-sacral region, 
but may be met with in the neck or any other part of the spine. It forms 
a rounded tumor, usually with a central dimple, and is due partly to the 
fact that the arches of the vertebras in the situation of the tumor have 
remained ununited, and partly to the fact that the membranes of the cord 
are there expanded and distended with dropsical fluid, and protrude 
through the abnormal fissure. In some instances the membranes alone 
protrude, and we have then a condition which is equivalent to hydro- 
meningocele. But much more commonly (especially if the disease be at 
the lower end of the spinal canal), the cauda equina is prolonged into the 
cavity. The filum terminale is then attached to the centre of the con- 
cavity of the cyst, causing the dimple to which reference has been made ; 
and the nerves of the cauda equina accompanying this to the posterior 
aspect then arch forwards across the cavity — double upon themselves — to 
reach their several foramina. If (as sometimes happens in such cases) 
the central canal of the implicated portion of the spinal marrow be dilated 
into a cyst, we have a condition which is the exact counterpart of hydren- 
cephalocele. 

2. Congenital or early developed dropsy (independent of malformation) 
probably always occupies the ventricles ; although in some cases, appa- 



HYDROCEPHALUS AND H YDRORRH ACHIS. 



941 



rently by accident, fluid becomes effused also into the cavity of the arach- 
noid, a. Chronic hydrocephalus (as it is generally called) sometimes 
commences during the later period of intra-uterine life, and the child is 
born already hydrocephalic. More frequently, however, the first mani- 
festation of the disease occurs between the time of birth and six months 
after that event. But it may come on at any time previous to the union 
of the cranial sutures ; and a few cases are recorded in which the super- 
vention of dropsy shortly after this union has caused the bones again to 
separate. The fluid of hydrocephalus is of higher specific gravity than 
cerebro-spinal fluid, and contains albumen, chloride of sodium, and urea. 
It mostly occupies the lateral, third, and fourth ventricles; audits gradual 
accumulation leads to their dilatation, to the flattening of the various pro- 
jecting ganglia, to the rounding of the several cavities, and to the enlarge- 
ment of their orifices of communication. In this way the lateral ventricles 
may become enormously dilated, the lateral walls of the third ventricle 
may be opened outwards, until they become horizontal, and lost, as it 
were, in the common floor of the general ventricular cavity, and the fora- 
men of Monro and the fissure passing thence backwards beneath the fornix 
may be so much dilated as to form a free arch-like communication (of 
which the expanded third ventricle forms the floor) between the two late- 
ral ventricles. The dilatation is not, however, always uniform or general. 
In some cases one lateral ventricle is much more enlarged than its fellow, 
or one part of a ventricle much more expanded than another part. In 
some cases, indeed, the posterior cornu becomes isolated from the rest of 
the cavity, and forms an independent cyst. Sometimes the third or fourth 
ventricle remains unaffected ; sometimes the dropsy is confined to one of 
these cavities. 

The effect of the gradual distension of the lateral ventricles upon the 
cerebrum is remarkable. We have pointed out that the various elevations 
and depressions in the ventricular walls become effaced, and that the late- 
ral ventricles tend to communicate freely with one another in consequence 
of the displacement upwards of the corpus callosum, septum luciclum and 
fornix. Concurrently with these changes the convolutions on the surface 
of the organ become unfolded, until finally, in extreme cases, their gray 
matter forms a continuous smooth plain over the dilated hemispheres, 
which at the same time become reduced in thickness to a half or quarter 
of an inch, and in some situations, probably to that of writing paper. 
Under these circumstances the dilated ventricles not unfrequently contain 
several pints of fluid ; indeed, cases are quoted by Trousseau in which 30, 
and even 50 lbs. were found in them. Occasionally, as in the well-known 
case of the man Cardinal reported by Dr. Bright, rupture of the surface 
of the brain or of its meninges occurs in the course of the disease, so that 
the fluid originally contained in the ventricles accumulates in the cavity of 
the arachnoid, and the brain lies collapsed and empty on the floor of the 
skull. 

The effects of hydrocephalus on the skull, on the nervous functions, and 
on the development of the child, are very important. As the dropsy in- 
creases, the head gradually enlarges at the expense of its lateral and upper 
part ; the two halves of the frontal bone, the parietal bones and the occipi- 
tal bone open (as Trousseau expresses it) like the petals of a flower, and 
are thrown outwards, while the intervals between them become propor- 
tionately widened. Consequently the forehead, the sides of the skull, and 
the occipital region all protrude, while the head becomes somewhat flat- 



942 



DISEASES OF THE NERVOUS SYSTEM. 



tenecl at the top. At the same time, some want of symmetry is usually 
apparent. The inordinate size and strange shape of the skull impart to 
the comparatively small face below it a peculiar aspect, which is aggra- 
vated partly by the emaciation which is usually present, and partly by the 
influence of the enlarging skull on the orbits and eyelids. The upper 
walls of these cavities are displaced downwards by the pressure to which 
they are subjected from above, while the upper eyelids, with the eyebrows, 
are drawn upwards over the forehead by the tension of the stretched 
pericranial integuments. The eyes consequently become prominent, and 
present a peculiar staring character, due to the fact that the sclerotic 
coat is habitually visible above the upper margin of the cornea. 

The integuments of the head become attenuated and tense, the super- 
ficial veins remarkably distinct, and the hair scanty and poor. The dis- 
placed bones also become thin, and the serrations of their edges irregular 
and straggling. Further, as the case progresses, nuclei of ossification 
appear irregularly in the tense membrane which intervenes between the 
separated bones, and these grow into irregular osseous plates, termed ossa 
triquetra. After a time, with the aid of these intercalated bones, the 
sutures and fontanelles may become entirely closed. This closure, how- 
ever, may not take place for twenty years or more. The patient almost 
always emaciates notwithstanding that his appetite may continue good, 
the frame remains undeveloped, and the limbs are puny and shrunken. 

b. Internal hydrorrhachis, or dropsy of the central canal of the spinal 
cord, is probably, like hydrocephalus, an affection of congenital origin or 
of early infancy. As has already been stated, it is sometimes associated 
with spina bifida ; it is sometimes also an accompaniment of hydrocephalus. 
The canal may be dilated more or less irregularly in its Avhole length, or 
may present circumscribed dilatations only, and may vary from a quarter 
of an inch to an inch in diameter. 

As regards the etiology of chronic hydrocephalus and hydrorrhachis 
commencing in foetal life or early infancy, we can only say that it is said 
to occur specially in rickety children, and in children of scrofulous or un- 
healthy parentage, and that its immediate cause is probably chronic inflam- 
mation or some condition allied to inflammation, involving the lining 
membrane of the affected cavities. 

Symptoms and progress — 1. The symptoms of chronic hydrocephalus 
are to a large extent comprised in the pathological account of the disease 
which has already been given, or may be surmised from the anatomical 
facts in relation to it there considered. As regards the invasion, it may 
be observed that in some cases progressive enlargement of the head, and 
the gradual supervention of the characteristic physiognomy of the disease, 
are the earliest indications of the presence of hydrocephalus ; while in some 
instances epileptiform convulsions, repeated from time to time, or other 
symptoms indicative of brain-disturbance, precede the appearance of any 
obvious change in the form or size of the skull. We may arrange the 
symptoms of the disease under three heads : namely, those dependent on 
the progressive enlargement of the skull ; those connected with the general 
nutritive functions : and those which depend on the involvement of the 
nervous centres, a. The general shape which the head acquires, and the 
peculiarities presented by the stretched integuments, the eyes, the eyelids, 
and the face have already been sufficiently described. We may mention, 
however, that fluctuation can generally be easily perceived in the course 
of the open sutures, and that these parts may often be seen to collapse 



HYDROCEPHALUS AND HYDRORRH ACHIS. 



943 



with inspiration and to dilate with expiration. Occasionally, as in the 
case of Cardinal, the dilated head, like a hydrocele, is more or less trans- 
parent. The increasing size and weight of the head render it before long 
difficult for the child to support it, and tend, among other things, to delay 
the acquisition of the power of walking. The young babe is apt to rest its 
head constantly on the pillow, or on the nurse's lap, rolling it about from 
time to time ; and even when the child can walk, it still has frequently to 
lay its head down, or to support it with its hands, and, under any circum- 
stances, w r alks with a slow and cautious gait. The latter peculiarities may 
be continued throughout adult life. b. The general nutritive functions are 
almost always seriously impaired. The child probably takes food well — 
nay, greedily ; but, notwithstanding this, it remains undersized and weak, 
and its face, trunk, and limbs become, as a rule, emaciated and shrivelled. 
The bowels are often confined, c. Not only are epileptiform convulsions 
often among the earliest symptoms of hydrocephalus, but similar convul- 
sions, or attacks of laryngismus stridulus, are very apt to come on at a later 
period of the disease; and even if they have been absent before, they may 
supervene at the time of puberty, or later. These, however, are not the 
only nervous phenomena present. The child is generally fretful and dull, 
its sight becomes impaired and sometimes lost, and occasionally also deaf- 
ness ensues ; the limbs are liable to spasmodic twitches ; and not unfre- 
quently the muscles, and more especially those of the lower extremities, 
become rigid ; they may also undergo atrophy. With the advance of age, 
we generally find gradually increasing hebetude or idiocy — loss of memory, 
incapability of mental exertion, or some special incapacity for learning ; 
we probably find, too, that the patient becomes irritable, passionate, or 
morose. Nevertheless, he occasionally remains fairly bright and intel- 
ligent. 

The duration of life is various. Hydrocephalic foetuses not uncommonly 
die in the act of birth. Death usually occurs, however, during the first or 
second year, from either convulsions, coma, or intermittent disorders. But 
life may be prolonged for five or ten years, or longer. In two cases quoted 
by Trousseau, from Frank, the ages at death were seventy-two and seventy- 
eight respectively. The prospect of life no doubt depends, to a consider- 
able extent, on the bulk to which the skull and its contents have attained, 
and on whether the disease has become stationary or not. It not unfre- 
quently, indeed, comes to a stand-still at a comparatively early stage, and 
the patient survives with a large head, a protruding forehead, and other 
more or less obvious indications of the affection which he labored under 
in infancy. But the prospects of life do not depend wholly on these con- 
ditions, for the man Cardinal, who lived to the age of thirty, had an 
enormously large head, and the ossification of his skull was not completed 
until two years before his death. 

2. The symptoms due to dropsy of the ventricles, coming on after the 
consolidation of the skull, are necessarily obscure, and none the less so that 
the dropsy is almost without exception dependent on the presence of some 
other grave lesion which has already produced cerebral symptoms. The 
special symptoms to be expected are those which would arise from pressure 
on the important ganglia situated on the floor of the ventricles ; or, if the 
accumulation be acute and abundant, and in these respects resembling 
intra-ventricular hemorrhage, those of almost sudden and profound coma, 
with general paresis. There is probably always more or less impairment 
of the mental functions, loss of memory, dulness and stupidity, attacks of 



944 



DISEASES OF THE NERVOUS SYSTEM. 



unconsciousness or convulsions, more or less want of control over the 
evacuations, and finally coma. But, besides these phenomena, there may 
be more or less marked hemiplegia, and not improbably some interference 
with the conclusiveness of some of the cranial nerves, or some impairment 
of speech. 

3. The symptoms referable to internal hydrorrhachis are also exceedingly 
vague. In some cases there is nothing either in the history or in the 
symptoms to indicate the presence of any affection whatever of the cord. 
In a case of Sir W. Gull's, and in some others that have been recorded, 
dilatation of the canal in the neck induced paresis of the upper extremities, 
with wasting of the muscles. It is natural, indeed, to assume that the 
symptoms of this affection should be those of pressure on the gray matter 
of the cord ; and the symptoms which have been presented by published 
cases accord in the main with this assumption. 

The clinical history of hydro -meningocele, hydrencephalocele, and spina 
bifida, and the treatment of these affections, belong rather to surgery than 
to medicine, and need not further occupy our attention. 

Treatment The treatment of dropsy of the brain or cord is exceedingly 

unsatisfactory. If indeed the dropsy be in the adult, and secondary to some 
organic lesion, the probability is that it will not be diagnosed. If it were 
diagnosed it would not lead us to adopt any specific treatment. In the 
chronic hydrocephalus of children, however, we so easily recognize the 
presence of the disease, there is such a field for treatment offered by the 
slowness 4 of the case and the gradual evolution of its various symptoms, that 
it is difiicult to believe that everything we do must be unavailing. Yet 
this is certainly true of the great majority of cases. The attempt has often 
been made to promote the absorption of the fiuid by the application of 
counter-irritants to the surface of the skull, or by the compression of the 
skull by bandages, or better, by the use of long strips of adhesive plaster 
applied uniformly over its surface. Trousseau states that in a case in which 
he adopted this treatment, sudden death was caused by the yielding of the 
bones of the base of the skull and the discharge of the dropsical fiuid by 
the nose. It has been recommended to tap the distended cavities by means 
of a fine trocar and canula. In using these, the puncture should be made 
vertically, at the edge of the anterior fontanelle, but avoiding the situation 
of the longitudinal sinus. A small quantity of fluid only should be removed 
at one time, and external pressure should be used to counteract the dimin- 
ished pressure within. The operation is not dangerous, and has often been 
performed with temporary benefit ; though no doubt there is risk that in- 
flammation may follow, or that a vessel may be wounded. For internal 
use, iodide of potassium, iodide of iron, and mercurials have been employed. 
Sir Thomas Watson suggests, on the recommendation of an old apothecary 
of his acquaintance, the exhibition thrice daily of about ten grains of a pill 
made by mixing two parts of crude mercury with one part of fresh squills 
and four parts of conserve of roses. It is stated that persistence in this for 
several weeks has cured more than one case of the disease. It is neverthe- 
less questionable whether any of the above plans of treatment are of real 
efficacy ; and whether any children, who would not otherwise have got well, 
have recovered under their influence. On the whole it seems to us that it 
is best to aim at promoting the child's general health by attention to' his 
diet and to his secretions, and by the use of iron, cod-liver oil, or other 
tonic medicines calculated to fortify his vital powers. 



CHOREA. 



945 



XII. CHOREA. (St. Vitus' s Dance.) 

Definition. — Chorea is a peculiar convulsive disorder, for the most part 
of early life, characterized by disorderly movements, which in the first in- 
stance are usually unilateral, but soon become general, and which tend as 
a rule to subside spontaneously after a few weeks' duration. 

Causation. — This affection occurs mainly among children between the 
ages of five and fifteen, or from the commencement of the second dentition 
to the end of puberty. It is 'not, however, very uncommon to meet with 
it in persons between fifteen and twenty-five ; and indeed it may occur, but 
occurs with extreme rarity, at any subsequent period of life. Dr. Graves 
records the case of a chemist who had chorea at the age of seventy, and 
M. Henri Roger that of a lady who was seized with it at the age of eighty- 
three. Chorea attacks females far more frequently than males. This 
preponderance in favor of the female sex is manifested even in early child- 
hood, but it becomes more pronounced as life advances ; and of adults who 
are attacked very few are men. Other predisposing causes are : hereditary 
influence, child-birth, and especially a previous attack of the disease. 
Trousseau draws attention to its frequent association with chlorosis ; but 
perhaps the most interesting fact in relation to the causation of chorea is 
the intimate connection which it has with articular rheumatism and cardiac 
disease. Not only does chorea often come on in the course of acute rheu- 
matism, not only does acute rheumatism occasionally come on in the course 
of chorea, but a large proportion of those victims of chorea whose cases do 
I not fall into either of these categories have suffered from acute rheumatism 
! at some period or other prior to the choreic attack. It has further been 
clearly ascertained : that by far the greater number of choreic patients 
present some cardiac defect ; that either the action of the heart is irregular, 
or there is what is supposed to be an anaemic murmur at the base, or there 
is distinct evidence of endocarditis, pericarditis, or both ; and that this 
cardiac defect (even if clearly of inflammatory origin) is often met with in 
cases in which there is no history of rheumatism, or comes on during the 
choreic attack without any associated implication of the joints. Rheuma- 
tism, therefore, and especially rheumatism attended with pericarditis or 
endocarditis, must be regarded as at least one of the most efficient of the 
determining causes of chorea. Other causes, which operate apparently inde- 
pendently of heart-disease or rheumatism, are overwork, anxiety, excite- 
ment, and, above all, sudden fright. 

Symptoms and progress. — Chorea generally comes on insidiously; and 
not unfrequently before any convulsive movements are recognized the child 
is observed to mope, to avoid its companions, to take no interest in its 
accustomed amusements or games, and to be incapable of fixing its atten- 
tion on its work, of committing lessons to memory, or even of readily 
recollecting. Indeed there is generally some real or apparent mental 
I deficiency, associated with more or less emotional disturbance, indicated 
by a tendency to caprice and fretfulness, to cry, and to be suspicious or 
j timid. These phenomena may go along with more or less general loss of 
i health and impairment of the nutritive functions. The first indications of 
the special nature of the disease under which the patient is laboring are 
j usually more or less restlessness or fidgetiness, and a certain clumsiness in 
| his movements : he cannot sit long in one place ; he is constantly shifting 
' his position or the position of one or other of his limbs ; he stumbles unac- 
60 



946 



DISEASES OF THE NERVOUS SYSTEM. 



coimtably in moving about the room or in going up and down stairs ; and 
he has a tendency to spill his tea or coffee, or to drop, or to knock against 
something else, whatever he essays to carry. The choreic movements are 
mostly first manifested upon one side, sometimes in the face, sometimes in 
the hand and arm, less commonly in the leg ; but soon they involve the 
whole side in a greater or less degree; and after a variable time, a few 
days or a few weeks, the affection probably extends to the opposite side of 
the body, and thus becomes universal, although there often still remains 
more or less distinct preponderance of the symptoms on one side. But 
this mode of access, though the most frequent, is by no means invariable. 
In some cases, when the affection comes on in the course of an attack of 
rheumatism, no obvious prodromal symptoms are presented. And some- 
times, especially when the disease is induced by violent emotion, its onset 
is sudden, and the symptoms may be general from the beginning. 

The phenomena of the fully-developed affection, although varying largely 
in degree, differ but little in kind, and are for the most part exceedingly 
characteristic. The convulsions affect, in a greater or less degree, the 
whole body. They are remarkable for their disorderly character; they 
are not rhythmical, neither are they simple alternate flexions and exten- 
sions ; but they consist in sudden impulsive movements, succeeding one 
another at irregular intervals, and involving now one group of muscles, 
now another, now one part of the body, now another, now several concur- 
rently.. The convulsions generally subside in some degree when the patient 
is sitting or lying down ; and (if they are not very violent) he is sometimes 
able to restrain them for a few moments ; but they become aggravated 
whenever he endeavors to execute voluntary movements, whenever any- 
thing occurs to excite him, whenever he feels that he is being observed. 
It hence happens that the medical attendant rarely sees him at his best. 
The choreic phenomena cease during sleep and under the influence of 
chloroform. The affection of the muscles of the face induces constant 
contortions of the features ; the eyebrows are at one time elevated and the 
forehead is thrown into transverse wrinkles ; at another time the brows 
are knit ; the eyes move suddenly and without purpose in various direc- 
tions ; the mouth is now opened, now closed, now drawn into various odd 
forms by the influence of the orbicularis and surrounding muscles. The 
face, moreover, wears a strangely vacant imbecile aspect. The tongue 
shares in these tumultuous movements. If the patient be asked to put it 
out, he opens his mouth wide and protrudes it with a jerk, and then as 
suddenly withdraws it, the mouth and jaws closing upon it with sudden 
violence. If he endeavor to answer questions, the convulsive movements 
of the face and mouth become aggravated ; and he has extreme difficulty 
in articulating his words, which come out in driblets as it were, slurred 
over, or uttered with a peculiar drawl, hesitation, or stammer. The diffi- 
culty of speech depends partly on the convulsive action of the lips and 
tongue; but not unfrequently also on spasmodic affection of the larynx and 
respiratory muscles, which compels him to draw his breath suddenly 
through the laryngeal orifice with a strange sound. In some cases, even 
when no attempt at speech is being made, odd croaking or grunting noises 
are thus from time to time produced. The actions of the muscles of the 
head and neck are probably as incoherent as those of the face, so that the 
head is sometimes jerked to one side, sometimes to the other, or thrown 
disorderly into various odd positions. No parts usually manifest choreic 
phenomena more strikingly than the upper extremity: all its segments are 



CHOREA. 



947 



involved in a greater or less degree ; the patient hitches his shoulder ; he 
moves his upper arm to and from his side; his forearm becomes flexed, 
extended, supinated, pronated : his hands and fingers execute the most 
grotesque and inco-ordinate movements. The general movements of the 
limb, when the patient uses it — when, for example, he endeavors to raise 
a glass of water to his lips — are curious to watch. By an effort of the will 
(if the case be not exceedingly severe) the glass ultimately reaches its 
destination, but it reaches it probably after many failures ; its progress is 
not arrested by a series of undulatory, tremulous, or backward and forward 
movements of the limb, but the different segments are suddenly and vio- 
lently plucked, as it were, by some invisible power first in one direction 
then in another, in the line of the intended movement, or in direct oppo- 
sition to it, or at right angles with it. The primary movement is overlaid, 
as it were, during its course with innumerable uncontrollable secondary 
movements, which retard it, aggravate it, and distract it. The lower 
extremities are affected similarly to the arms. They are moderately quiet 
when the patient is at rest, but as soon as he begins to use them, as soon 
as he begins to walk, their movements become inco-ordinate, jerky, 
tumultuous. To quote Sir Thomas Watson's words : ' when the patient 
intends to stand or sit still, her feet scrape and shuffle on the floor ; or one 
of them is suddenly everted and then twisted inwards, or perhaps is thrown 
across the other ; and if she endeavor to walk, her progress is indirect and 
uncertain ; she halts and drags her leg rather than lifts it up, and advances 
with a rushing or jumping motion by fits and starts.' The muscles of the 
trunk partake in the general convulsive movements, and the body is 
twitched and contorted with sudden violence into all kinds of odd and 
unaccountable positions. It must be added: that mastication and deglu- 
tition are often rendered difficult by the spasmodic movements of the 
muscles engaged in these operations ; that respiration is frequently inter- 
rupted and rendered irregular, jerky, and noisy, by involvement of the 
diaphragm ; and that sometimes in severe cases the sphincters of the 
rectum and bladder relax, and the evacautions escape involuntarily. In 
mild cases the patient is able to walk about, though with more or less 
difficulty or clumsiness, and it may be to feed and dress himself. In more 
severe cases locomotion is impossible, and he has to be confined to his bed ; 
he becomes, moreover, quite incapable of using his hands for any purpose. 
In the worst form of the disease the condition of the patient is miserable 
in the last degree, and pitiable to behold. His features and head and neck 
are in constant motion ; his arms are flung out first in this direction and 
then in that, his fingers and hands meanwhile executing the most varied 
and fantastic movements ; his lower extremities are probably little less 
violently convulsed than his arms ; and his trunk is constantly being 
twisted about in bed, now into the prone position, now into the supine, is 
now doubled up, now straightened out again, now caught by some strange 
contortion. 

The phenomena above described are not, however, the only nervous 
phenomena which attend chorea. There is always impairment of the 
strength of the affected muscles, some paresis — a fact especially easy of 
recognition in cases of unilateral chorea. In some cases, indeed, the con- 
vulsive phenomena may be replaced by more or less complete hemiplegia 
or even paraplegia. Sometimes the hemiplegic or paraplegic symptoms 
precede the onset of the choreic movements. More frequently they come 
on in the course of the disease and supplant them. Some impairment of 



948 



DISEASES OF THE NERVOUS SYSTEM. 



sensation is also observable in the great majority of cases ; and its degree 
Las more or less relation to the severity of the convulsions or to the degree 
of paralysis present. Occasionally the anaesthesia is almost absolute. The 
fatuous aspect of the patient in the early stage of chorea has already been 
referred to ; this aspect continues and even becomes aggravated during 
the continuance of the disease. No doubt it depends largely upon the 
various spasmodic movements in which the muscles of expression and 
those that move the eyeballs are implicated ; but there is good reason to 
believe it is to some extent governed by the fact that intelligence does 
actually fail to a greater or less extent during the presence of the malady. 
Emotional sensibility, on the other hand, is somewhat exalted. Sometimes 
the eyesight fails. 

Subordinate symptoms of more or less importance are apt to attend the 
progress of chorea. The patient's appetite is often bad, or capricious, or 
fails. His bowels are confined. His nutrition becomes impaired. He. 
suffers from palpitation, and, as has already been pointed out, he is liable 
to functional or organic disease of the heart, either of which may supervene 
in the course of his attack. There is a striking absence of febrile symp- 
toms during the progress of the disease. 

The issue' of chorea is in the vast majority of cases favorable. Some- 
times (if for example the choreic movements come on in the course of 
acute rheumatism and involve one arm only) the patient recovers in the 
course of a few days. More commonly the disease continues for a period 
varying between four or five weeks and three months. In some instances 
it is prolonged for two or three years or more. But in these cases it is 
usually continued by successive relapses, each coming on before the symp- 
toms of the preceding attack have wholly disappeared. Indeed, patients 
who have had one attack of chorea are peculiarly liable to subsequent 
attacks, which come on at irregular periods and under the slightest provo- 
cation. Very rarely, indeed, chorea lasts for many years or for a lifetime. 
"When the disease is fatal, it rapidily assumes aggravated proportions. The 
spasms are incessant ; their violence and continuance prevent sleep, or 
allow only of occasional short snatches of sleep ; and they interfere seri- 
ously with the ingestion of food, and thus rapidly induce mental and 
bodily exhaustion. Further, the evacuations escape unconsciously, or at 
all events are uncontrolled ; and partly on this account, partly in conse- 
quence of the constant friction to which the trunk and limbs are subjected 
by their never-ceasing movements, the skin becomes chafed in innumerable 
places, and bed-sores form over the various prominences, more especially 
over the elbows, hips, and sacrum. Often also the child bites its lips until 
they bleed ; and very frequently the red portions of both lips become split 
by numerous deep vertical fissures. Death, which may be preceded by 
delirium, is generally due to asthenia. But its immediate cause may be 
the supervention of eryspelas or the consequences of heart disease. 

The recovery from chorea (putting cardiac disease out of the question) 
is generally complete :'the patient regains his muscular strength, and his 
intelligence is restored to him unimpaired. But it is not always so. Oc- 
casionally he remains more or less feeble-minded, or even becomes insane, 
or lapses into a fatuous condition. In some cases, too, the implicated 
muscles remain enfeebled ; and they may then undergo slow contraction 
or atrophy, or both. In a chronic case which has been under our observa- 
tion, and in which the general symptoms were undistinguishable from those 
of genuine chorea, the choreic movements of the lower extremities were 



CHOREA. 



949 



associated with marked rigidity of the' muscles, some degree of flexion at 
the hip and knee joints, with overlapping of the knees from the prepon- 
derant action of the adductors of the thighs, and a tendency to talipes 
equino-varus — facts which seem to indicate that degenerative changes of 
the lateral columns of the cord had supervened. 

Morbid anatomy and pathology — The pathology of chorea is confessedly 
obscure ; it is not known either what parts of the central nervous organs 
are the seat of disease, or what is the nature of the morbid process going 
on in the affected parts. The facts of its unilateral commencement and 
general unilateral tendency point, however, to disease, either of the corpus 
striatum and optic thalamus, or of the corresponding cerebral hemisphere. 
And doubtless one or other of these parts is the main seat of the lesions 
on which chorea depends. But there are many features of the disease, 
such as the occasional implication of the muscles of phonation, respiration, 
and deglutition, and the frequent occurrence of functional disturbances of 
the heart, which would seem to imply involvement of the medulla oblon- 
gata. And the resemblance of the choreic movements to those of loco- 
motor ataxy are certainly suggestive of implication of the cord. Then as 
regards the nature of the disease, its frequent connection with rheumatism 
and cardiac disease has suggested at least two hypotheses. One, origin- 
ating with Dr. Kirkes, and since ably supported by Dr. Hughlings Jack- 
son, is to the effect that the symptoms are due to obstruction by minute 
emboli of the smaller branches of the arteries supplying the corpus striatum 
and contiguous parts, with consequent scattered minute patches of conges- 
tion and softening. The objections, however, to this view are obvious. 
Obstruction of the arterioles has been observed only in a very small num- 
ber of cases, and it is doubtful if in these the obstructions were embolic or 
thrombotic. Besides which, it is not only difficult to believe that showers 
of minute emboli should be distributed throughout the minute vessels sup- 
plied to one corpus striatum or one side of the brain only, and that at some 
later period there should be a similar limitation of such embolic patches to 
the region supplied by the middle cerebral artery of the other side : but it 
is difficult to understand why large emboli should not be occasionally in- 
termingled with the smaller ones, and cause sudden hemiplegia by obstruct- 
ing a large vessel, and why small emboli shed simultaneously should not 
become blended by fibrinous coagulation around them into one or two con- 
crete masses. [There are several other objections to this theory. Among 
them is the absence of the disordered movements during sleep. If these 
are really the consequence of embolism of the minute cerebral arteries, the 
irritation upon which they depend must be a constant one, allowing of no 
remission. It is also difficult under this theory to explain the sudden oc- 
currence of the symptoms of this disease in the midst of what appears to 
be good health after a powerful emotion, such as fright, or their abrupt 
cessation either as a result of treatment or from some other cause. An- 
other fact which also tends to disprove this theory is the more frequent 
occurrence of chorea among girls than among jboys, while the cause to 
which this is traced — vegetations upon the valves — must, as a consequence 
of rheumatism, be more common in the male sex. This is an objection 
which cannot be entirely gotten over by ascribing the greater frequency of 
chorea in girls to the greater excitability of their nervous systems.] The 
other hypothesis is that the same disease which affects the valves of the 
heart or the joints in rheumatism attacks also the smaller cerebral vessels 
or the ultimate tissue of the central nervous organs, a view which might 



950 



DISEASES OF THE NERVOUS SYSTEM. 



well explain the supervention of caMiac disease in chorea, as well as the 
dependence of chorea on rheumatic fever. A main objection to this view 
is the fact that it is simply conjectural, and wholly unsupported by ana- 
tomical evidence. Moreover, it fails, as also does the embolic hypothesis, 
to explain those cases which are due to fright or other powerful emotions, 
and in which, so far as we know, the heart remains sound. 

It seems to us, however, that the clinical phenomena of chorea cannot 
possibly be referred to alfection of any circumscribed region of the nervous 
centres ; and that, whether the seat of the disease be thus limited or not, 
the embolic hypothesis is altogether inadequte as an explanation of the 
nature of the morbid processes to which the clinical phenomena are linked. 
The symptoms are partly intellectual, partly emotional, and referable partly 
to the functions of the voluntary muscles, partly to the cutaneous sensi- 
bility, and partly also to the bulbar nerves, which subserve articulation, 
deglutition, respiration and the motor functions of the heart ; they would 
seem therefore to be connected at the same time or successively, and in 
different degrees, with the cerebral convolutions, the ganglia at the base, 
the pons and medulla, and the spinal cord. The valuable paper recently 
read by Dr. Dickinson before the Medico-Chirurgical Society is strongly 
confirmatory of this view. He shows, from the results of careful post- 
mortem examinations made on several fatal cases of chorea : that there is 
a general tendency to dilatation of the smaller vessels, more especially the 
arteries, throughout the substance of the brain and cord ; that this dilata- 
tion is attended with exudation into the tissues immediately surrounding 
the vessels, and occasionally with small hemorrhages indicated by the 
presence of blood crystals and the like, or patches of sclerosis ; that these 
changes are most advanced in the corpora striata, in the nervous matter in 
the neighborhood of the trunks of the middle cerebral arteries, and in the 
posterior and lateral portions of the gray matter of the cord, mainly at the 
upper part; and further, that in all these regions the morbid conditions 
tend to be symmetrically arranged. And on the basis of these facts, and 
admitting that chorea is associated generally with rheumatism, in the larger 
proportion of cases with heart-disease, and in some cases with no inflam- 
matory or structural disease of any organ, he comes to the conclusion (in 
which we are disposed to concur) that chorea depends 'on a widely-spread 
hyperemia of the nervous centres, not due to any mechanical mischance, 
but produced by causes mainly of two kinds — one being the rheumatic 
condition, the other comprising various forms of irritation, mental and re- 
flex, belonging especially to the nervous system.' The tendency which 
the vascular changes have (on Dr. Dickinson's showing) to induce sclero- 
sis in the tissues which surround the vessels well explains the wasting of 
muscles, rigidity of limbs, and permanent paralysis, which occasionally 
complicate chorea or supervene upon it. 

Treatment — For few diseases have so many specific remedies been 
vaunted as for chorea ; yet few diseases are really so little amenable to 
treatment. It must never be forgotten, in weighing the value of medi- 
cines in this affection, that the great majority of cases tend to get well 
spontaneously in the course of a few weeks. Sydenham recommended 
bleeding and tartrate of antimony, and cured his patients by these means; 
and even Sir Thomas Watson advocates local bleeding when there is a 
fixed pain in the head. Large doses of antimony, indeed, have been 
strongly recommended by many physicians. Iron is a favorite remedy ; 
so is arsenic ; and so also is sulphate of zinc, given in doses, to commence 



EPILEPSY. 



951 



with, of a grain or two three times a day, which are slowly increased by 
successive increments, until from 20 to 40 grains are given at a time. 
Iodide of potassium is lauded by some ; bromide of potassium by others ; 
phosphorus by others. Of medicines derived from vegetable sources we 
may name turpentine, strychnia, cannabis Indica, opium, belladonna, and 
various anti-spasmodics. Exercise, frictions, and cold baths, more espe- 
cially shower-baths, have all their advocates. We must confess that, in 
our own opinion, few, if any, of the above remedies have any real influence 
over the course of the disease ; if, however, we have any bias, it is in 
favor of arsenic, given in small doses, and continued for some length of 
time. [Another plan of giving arsenic, which has a reasonable degree of 
success in its favor, is to gradually increase the dose until the amount 
which the patient can bear without its provoking vomiting or nausea is 
reached. This amount should be continued until the cure is complete.] 
We believe, however, that real benefit accrues in a considerable number 
of cases from improvement of the general health ; that, in this point of 
view, tonics (among which iron holds an important place) are useful, as 
also are careful attention to hygienic measures, good wholesome diet, early 
hours, avoidance of excitement, gentle exercise, cold or tepid bathing, and 
change of scene and air. Again, our treatment may often be usefully 
directed by the nature of the malady (if any) with which the chorea is 
associated ; thus, when rheumatism is present, or chorea is a legacy left 
by rheumatism, anti-rheumatic treatment may be of great service. In 
those severe cases in which the convulsive movements are incessant, and 
the patient has little or no rest, and death consequently threatens, narcotics 
and stimulants would seem to be indicated. The inhalation of chloroform 
arrests the convulsive movements so long as the patient is under its influ- 
ence ; opium, morphia, or chloral in large doses has the same effect. But 
it must be admitted that, notwithstanding the temporary ease they give, 
the progress of the disease towards its fatal end is rarely, if ever, retarded 
by their use. The patient should then be supported by food and stimu- 
lants. Further, every precaution should be taken to prevent the patient 
from injuring himself in his contortions, and all sores that form upon the 
surface of the skin should be at once treated, and protected from further 
injury. 

It may be pointed out, in conclusion, that chorea is apt to spread 
among children, apparently by imitation ; that choreic patients are often 
rendered worse by their association with patients of the same class; and 
that hence precautionary measures directed against such accidents should 
be taken. 



XIII. EPILEPSY. ECLAMPSIA. INFANTILE 
CONVULSIONS. 

A. Epilepsy. (Morbus comitialis vel sacer.) 

Definition It is difficult, if not impossible, so to define epilepsy as 

within the limits of a mere definition to include all the varieties of form 
which it assumes. Speaking generally, it is a functional disorder of the 
nervous centres, characterized by sudden seizures of temporary duration 
and occurring at irregular intervals, in which the patient either loses con- 



952 



DISEASES OF THE NERVOUS SYSTEM. 



sciousness or presents some other form of mental disturbance, or lias tonic 
or clonic convulsions, or all of these phenomena in sequence. For a true 
conception of the disease, it must be understood that, however mild the 
attacks may be, all the phenomena which have been enumerated are 
potentially present in them, and may be expected to occur in combination 
during the progress of the disease. 

Causation The causes of epilepsy are very obscure. The disease has 

been attributed to all sorts of circumstances which have probably little or 
no influence in its production. Among those to which most importance 
has been attached may be mentioned sudden fright, the witnessing of an 
attack of epilepsy, long-continued anxiety, overwork, drink, abuse of 
absinthe, and venereal excesses, especially masturbation. But their im- 
portance as exciting causes has been greatly over-estimated. It is con- 
sidered by Trousseau that the real share of each one of them (excepting 
fright) in the production of the disease is yet to be proved; and Russel 
Reynolds remarks of excessive venery and masturbation, that far too much 
importance has been attached to them. Hereditary predisposition, on the 
other hand, exerts a remarkable influence over the development of epilepsy. 
It is to be observed, however, that it is not so much epilepsy itself which 
is hereditary (although no doubt it is so in a high degree), as that epilepsy 
becomes hereditary in families, among the members of which neuroses, 
such as epilepsy, insanity, hysteria, and the like, prevail. It is not un- 
common to find in such families that several of the children are epileptic, 
or that one is epileptic, one suffers from chorea, one is an idiot, and so on. 
But the predisposition to epilepsy may be acquired : for it is certain 
that many of those persons who subsequently become epileptic have 
suffered in infancy from convulsions, which were induced by teething 
or other accidental circumstances. Epilepsy occurs pretty equally in 
both sexes. The first attack may come on at any period of life — in early 
childhood or extreme old age ; but it occurs far more frequently between 
the ages of ten and twenty (more precisely, perhaps,, during the time of 
puberty) than it does at any other period of life. Dr. Reynolds points 
out that there is comparative immunity between the ages of twenty-five 
and thirty-five ; but that the outbreak of the disease becomes comparatively 
frequent again about the age of forty. After this time its primary appear- 
ance is extremely rare. 

Symptoms and progress. — The phenomena of epileptic attacks are so 
various, they differ so widely from one another in different cases, both in 
their characters and in their grouping, that it is- impossible to give a com- 
prehensive, and at the same time graphic, account of them, excepting by 
the aid of illustrative cases. Our space forbids the adoption of this course. 
We shall, therefore, begin with the description of a typical attack of the 
disease, and then discuss the variations to which attacks are liable. 

The epileptic fit is not unfrequently preceded by a well-marked prodro- 
mal period, lasting in different cases from a day or two to a few seconds. 
But under any circumstances, the fit itself comes on suddenly ; the patient 
probably utters a cry, loses consciousness, and, if standing, falls down as 
if shot on his face or on the back of his head ; his muscles become rigid, 
especially perhaps, those of one side, and at the same time slowly contract; 
and respiration ceases. After these phenomena, which constitute the first 
stage of the attack, have lasted for a few seconds, the second stage super- 
venes. This is characterized mainly by return of respiration, lividity of 
surface, distension of the veins of the head and neck, clonic spasms, which 



EPILEPSY. 



953 



are mostly unilateral, biting of the tongue, and continuance of unconsci- 
ousness. At the end of a minute or two this stage also comes to a con- 

I elusion, the lividity disappears and the convulsions cease, but the patient 
probably still continues insensible ; presently, however, consciousness re- 
turns in some degree, and he either rapidly recovers, or remains confused 
or maniacal, or in a state of stupor, for some hours, or it may be a day or 

i two, before complete recovery takes place. 

The prodromal period is present probably in about half the total number 
of cases, and if present in one attack is most likely present in other attacks 
occurring in the same patient. Moreover, under such circumstances the 

I premonitory symptoms continue probably, at any rate for a time, of the 
same kind. Those which precede the attack by some hours or a day or 
two are the least common, and although perhaps apparent enough to the 
patient or his friends, are on the whole slight in degree and vague. They 

\ consist, for the most part, in some modification of the patient's intelligence, 

j feelings, or habits ; he gets dull and incapable of mental exertion or of 
attention to business, sullen or low-spirited ; or his manner and conversa- 
tion become sparkling and lively, and his spirits unaccountably buoyant 

! and jovial — he may even be furiously maniacal ; or there is simply some- 
thing in his look — a wildness in his eye, or a dulness and heaviness of 
expression — which is not natural to him. The more characteristic pre- 
monitory symptoms are those which precede the fit by a few minutes or a 
few seconds only. They are remarkably various. In some cases they 
consist in the spasmodic contraction of certain muscles : the expressional 
muscles of one side of the face twitch ; or the hand and arm are convulsed 

' and gradually carried upwards towards the face ; or the lower extremity is 

I equivalently affected ; or the muscles of one side of the head and neck 
contract and carry the face over the opposite shoulder ; or the muscles of 
several or of all these regions are simultaneously involved. Sometimes 
the epileptic fit is preceded by vertigo, or sickness, or by severe pain or 
some undefinable sensation referred to the head, throat, chest, abdomen, 
or some other part. Not unfrequently the premonition is furnished by 
what has been termed the epileptic aura — a sense of coldness, heat, or 
pain, starting from some point, say the finger or toe, the abdomen or chest, 
or it may be from the seat of some former injury — which seems gradually 
to ascend until it reaches, as the case may be, the epigastrium, the pre- 
cordial region, or the head, when insensibility suddenly supervenes. In 
some cases the attack is ushered in by some hallucination of the senses : 
the patient perceives some peculiar smell ; or he hears strange sounds, and, 
it may be, voices ; or he sees definite forms before his eyes — animals, de- 
parted friends, witches, devils. Not unfrequently, again, the premonitory 
symptoms consist in some odd mental disturbance : the patient experiences 
a sudden horror or trouble, or finds himself engaged in some special train 
of thought or perplexed by some problem or the plot of some story or 
strange combination of circumstances. It is curious that these mental 
perplexities which seize upon the patient are often entirely forgotten after 
the occurrence of the fit, yet that the same perplexity is repeated (exactly 
as the drawing up of the arm or the occurrence of an aura is repeated in 
other cases) before every epileptic attack. 

The most constant feature of the first stage of the fit is the sudden onset 
of absolute unconsciousness. This may be momentary only, or may be 
prolonged throughout the whole of the first and second stages, and for two 
or three minutes or more. As we shall afterwards show, it is sometimes 



954 



DISEASES OF THE NERVOUS SYSTEM. 



absent. This unconsciousness while it lasts is profound ; the patient neither 
sees, nor hears, nor feels, nor can be roused by any means at our command. 
The convulsions which attend this stage are tonic ; they consist in the 
supervention in the affected muscles of great rigidity, attended in the first 
instance with fibrillar movements, and a tendency for certain muscles 
gradually to overcome their antagonists. They are rarely general, or it 
general they afiect one side more powerfully than the other ; they are in 
fact almost always unilateral, and sometimes limited to the side of the face 
or head and neck, or to the arm. The face becomes hideously distorted, 
and the tongue probably thrust between the teeth ; the head, from con- 
traction of the sterno-mastoid and other muscles drawn down obliquely on 
one side, the face being thrust over the opposite shoulder ; the trunk con- 
torted ; and the arm or leg flexed or extended. At the same time the 
respiratory and laryngeal muscles become fixed, and the acts of respiration 
cease entirely. The spasms are sometimes wholly absent. The epileptic 
cry which ushers in the attack occurs only in a limited number of cases. 
It varies in character, is sometimes a loud shriek, sometimes a hoarse 
groan, and is usually very distressing to hear. It occurs (as Dr. Eeynolds 
points out) once only, and appears to depend on the sudden emission of 
breath through the constricted glottis caused by the spasmodic contraction 
of the expiratory muscles. The pupils are dilated and insensible to light. 
If the patient be closely observed at the onset of his attack, his face will 
usually be seen to be suddenly overspread with a death-like pallor, which 
persists for a few seconds, but gradually, during the progress of the first 
stage, becomes replaced by redness and turgidity. In some instances no 
change whatever of color can be discovered. In association with the phe- 
nomena here enumerated there is usually extreme feebleness of pulse. 
Although the patient generally falls with sudden violence, he sometimes 
slips down quietly, almost as if by design ; and if the loss of conscious- 
ness be momentary only he sometimes remains motionless, standing or sit- 
ting, or merely staggers. The first stage usually lasts from ten to thirty 
or forty seconds. 

The second stage is attended with continuance of unconsciousness. 
The face has usually by the time of its commencement become livid and i 
bloated, and the veins of the head and neck distended ; but this lividity 1 
and over-distension of the vessels slowly subside during its continuance. 
The tonic spasms cease, to be replaced by clonic spasms. These, which 
consist in alternate powerful contractions of flexors and extensors or other 1 
groups of antagonistic muscles, may be general ; but they are more com- 
monly one-sided and limited to those parts which had previously been the 
seat of tonic contraction. The pupils oscillate, the eyelids and muscles of 
expression work, the mouth is alternately opened and closed with violence, 
and the protruded tongue, caught between the teeth, is apt to get severely 
bitten, the muscles of the head and neck and those of the trunk are con- 
vulsed, and the arm and leg execute powerful movements of extension and 
flexion. At the same time probably the feces and urine are discharged 
involuntarily. The respiratory acts are resumed at the commencement 
of this stage, and during its course are violent, jerky, noisy, and labored. 
The skin is cold; profuse sweat breaks out ; the pulse is full ; the heart 
beats violently. Mucus accumulates in the mouth and fauces, and mingled 
with the blood yielded by the bitten tongue, escapes from the lips. The 
symptoms of this stage, violent in the beginning, gradually subside ; and 



EPILEPSY. 



955 



at the end of a few seconds, a minute, or at most two or three minutes, 
the patient draws a deep sigh, and the second stage is completed. 

The condition of the patient in the third stage varies. Sometimes he 
recovers almost instantaneously, and appears at once in his normal health ; 
but more commonly he lies for some minutes or for half an hour in a con- 
dition of profound coma, from which it is impossible to arouse him. 
Sooner or later, however, consciousness slowly returns ; he opens his eyes 
and gazes stupidly or wildly about him ; he tries to speak, but mumbles 
unintelligibly or incoherently, or fails to produce any articulate sound; 
he tries perhaps to get up, and his movements and demeanor resemble 
those of a drunken man ; sometimes he becomes wildly maniacal, some- 
times falls into a state of trance or ecstasy. It not unfrequently happens 
that the patient lapses into a more or less profound sleep, interrupted it 
may be from time to time by slight convulsive twitchings. Muscular 
weariness, a sense of general bruising, headache, vertigo, restlessness, 
severe menial or emotional disturbance are apt to remain for some hours 
or even for a few days after the fit. After the attack the patient often 
passes a large quantity of limpid urine; and owing to the extreme disten- 
sion of the vessels of the head and neck and upper part of the trunk, 
minute extravasations of blood are apt to occur during the fit, and the 
surface of these parts to become more or less thickly studded with per- 
sistent hemorrhagic points, or petechias. 

The above account applies to those fits, typical in their severity and in 
the sequence of their phenomena, to which the names epilepsia grarior 
and haut mal have been given. But in a large number of cases either 
the fit does not pass beyond the prodromal stage ; or various of the stages 
are absent, or so rapidly completed, or so blended with one another, that 
they escape observation ; or some of the features of the malady are aggra- 
vated ; or new features are superadded. Most of these attacks come 
under the denomination of epilepsia mitior, petit mal, or epileptic vertigo. 

In some cases the patient is affected with an occasional sudden spasm 
of one side of the face, or of one sterno-mastoid ; or his hand closes, and 
the arm is gradually drawn up or flexed ; or he experiences some one of 
those sensory hallucinations which have been previously enumerated ; or he 
has an aura, or a sudden attack of headache, giddiness, sickness, or faintness. 
In other words, he is attacked with some one of the prodromal symptoms 
which are known to usher in epilepsy. Now it does not at all necessarily 
follow that the sudden occurrence of such phenomena, or even their occa- 
sional repetition, proves that the patient is epileptic; but it is certain that 
of those persons who suffer from them, some become epileptic sooner or 
later; and that those epileptics whose fits are preceded by warning symp- 
toms, not unfrequently have such warnings without fits following them. 
There can be no doubt that such attacks must, under these circumstances, 
be regarded as epileptic. They are, in fact, abortive epileptic fits. In 
some instances the patient's seizures consist in little more than a momen- 
tary interruption to the continuity of his thoughts. He is engaged in 
talking, and suddenly for a second or two becomes quiet, and then resumes 
the thread of his conversation as if nothing had occurred ; or instead of 
ceasing to speak he may utter some incoherent sounds, or words and ex- 
pressions utterly alien to the subject in which he was engaged. If he be 
closely observed at this moment, his pupils will probably be seen to dilate, 
his face to become momentarily pale, and then perhaps with returning con- 
sciousness a little more congested than natural. During the momentary 



956 



DISEASES OF THE NERVOUS SYSTEM. 



attack the patient may become absolutely unconscious, and his mind may 
be a blank ; or, although unconscious to everything about him, he may be 
the subject of a sudden trouble, perplexity of mind, or horror — some mo- 
mentary nightmare, as it were. Sometimes he utters a shriek and reels 
or staggers, or performs a rotatory movement, and then without falling to 
the ground recovers. Sometimes he is seized with unconsciousness lasting 
for a few seconds, or for a minute or more, and remains sitting or standing, 
or in whatever other position the fit surprised him in, his features meanwhile 
being perfectly passive or presenting convulsive twitchings. In some cases 
the wholly unconscious patient will go on during his unconsciousness with 
the work in which he was engaged at the time of seizure ; if walking he 
will continue to walk, if running he will go on running. Trousseau men- 
tions the case of a young amateur violinist who, during attacks of short 
duration, would go on playing with perfect accuracy as if he were still 
in his ordinary senses. There are other cases, again, in which the patient, 
during his attack of unconsciousness, performs strange actions, which have 
nevertheless an aspect of purposiveness about them, but of which he has no 
recollection whatever when consciousness returns. They seem in fact like 
the translation into action of the fragment of a dream. Thus, sometimes, 
while walking, perhaps in the street, he all at once begins to run rapidly, 
avoiding all obstacles, and then coming to himself discovers himself unac- 
countably far from his destination or from the place at which he lost his 
senses. Trousseau cites the case of a magistrate who, in such an attack, 
suddenly left the court over which he was presiding, went into the council 
chamber, made water in a corner of the room, and returned to the court 
entirely ignorant of the strange act that he had committed. Sometimes 
the patient will dance or sing, or peer about in various directions as if in 
search of something which he had lost or mislaid. But perhaps the most 
important, if not the most remarkable, of these aberrant forms of epilepsy 
are those in which the patient is seized with sudden and unaccountable 
fury, tears his clothes, or destroys anything that is near him, belabors the 
friend or servant that is with him, or rushes out of the house and attacks 
the first stranger that he meets, or jumps from the window, or in some 
other way maims or kills himself, and moreover not unfrequently accom- 
plishes such acts with apparent definiteness of purpose. Thus a husband, 
apparently waking out of sleep, will beat or strangle his wife with the utmost 
ferocity; a man walking along the street will, at the moment when the 
impulse is upon him, make an unprovoked and violent onslaught on who- 
ever chances to come near. Now it must be borne in mind that in all the 
varieties of seizure, in all the different forms of epileptic vertigo, which 
we have been considering, the only appreciable part of the attack may be 
the temporary unconsciousness, or delirium, together with the various spe- 
cific motor phenomena which have been enumerated, and utter uncon- 
sciousness or forgetfulness of what has passed in the attack. There may 
be no premonitory symptoms, no tonic or clonic convulsions, no change of 
color, no succeeding bodily or mental suffering. On the other hand, care- 
ful observation will often reveal the presence in a. more or less modified 
form of some of the more ordinary features of the typical epileptic fit. 
There may be slight premonitory symptoms; there is generally a sudden 
pallor or ghastliness at the commencement of the attack, soon followed by 
more or less redness and lividity, and in connection therewith dilatation of 
pupils, rolling of the eyes, or twitching or more violent convulsive move- 
ments of the muscles of the face or one of the limbs ; and, further, ver- 



EPILEPSY. 



957 



tigo, confusion of mind, or other such conditions may remain for a longer 
or shorter time after the subsidence of the fits. 

The first epileptic fit may also be the last; but in the great majority ot 
cases it forms the prelude to subsequent attacks, which may come on at 
various intervals for months or years or during the whole subsequent life- 
time of the patient. Sometimes the fits recur with more or less irregu- 
larity at intervals of a week, a month, two or three months, or a year, or 
more. There may then be a single fit at each recurring period, or there 
may be two or three, or a dozen, or more, succeeding one another more or 
less rapidly during a period of twelve or twenty-four hours. In some in- 
stances frequent fits occur habitually day and night. It occasionally hap- 
pens that, as the general health improves or age advances, the fits become 
less and less frequent, and at length recur at irregular intervals of years, 
or disappear altogether. It must be borne in mind, however, that those 
who have once been epileptic, even if five, ten, or a dozen years have 
passed since the last attack, are still not unlikely to have a relapse; and, 
again, that patients whose fits have hitherto occurred only at long inter- 
vals, not unfrequently suffer from aggravation of the disease — the fits 
rapidly increasing in frequency, and recurring in large numbers day and 
night for weeks together. Sometimes, when the attacks follow one another 
very rapidly, the patient falls into the status epilepticus — a condition in 
which he remains insensible for many hours, sometimes for a day or two, 
and which has often been referred to the persistence of a single fit ; it is 
made up, however, of a succession of fits, linked together by persistent 
epileptic coma. 

Convulsive fits recur, as a rule, much less frequently than attacks ot 
epileptic vertigo ; yet when they recur at long intervals they are very liable 
to be repeated several times within a limited period. Epileptic vertigo 
may come on habitually twenty, thirty, or forty times, or even as many 
as a hundred times in the day. According to Dr. Reynolds, cases of the 
haut mal are nearly twice as common as cases of the petit mal ; there can 
be little doubt, however, that the petit mal is much more frequent than is 
generally supposed, and that many persons accounted healthy, and who 
never consult a doctor, are liable to occasional slight seizures. Attacks 
of the haut mal not unfrequently, however, alternate with those of epi- 
leptic vertigo ; and still oftener patients who are subject to the former 
have abortive seizures represented by the aura only. On the other hand, 
although epileptic vertigo often constitutes the only form of seizure from 
which patients suffer, attacks of a severer kind are in such cases always 
liable to supervene. 

The circumstances which determine the epileptic fit in those who are 
liable to fits are not generally discoverable. They often, at all events 
when they first appear, come on only in the night, either, it is said, at the 
moment of going to sleep, or at the moment of waking ; and, even when 
they take place both day and night, they often occur mainly at night-time. 
It is not uncommon for them to attack women at the monthly periods ; 
yet it still more frequently happens that epileptic women do not suffer 
specially at the time of menstruation ; and they escape, as a rule, during 
parturition, a time at which eclampsia has a special tendency to super- 
vene. In some cases, the fit seems to be induced by severe mental labor, 
by emotion, by a debauch. It has occurred during the act of coitus. 
Sometimes, when the attack is preceded by an aura starting from some 
accessible point, it may be induced by irritation of that point. Thus, we 



958 



DISEASES OF THE NERVOUS SYSTEM. 



knew one case in which it was invariably excited by compression of a 
certain tender spot in the abdominal walls ; and we have met with another 
in which, for many weeks, fits were brought on day and night whenever 
the patient's legs were moved voluntarily or involuntarily whether he was 
awake or asleep. 

The condition of epileptic patients in the intervals between their seiz- 
ures is very various. In a large proportion of cases they appear to be in 
the enjoyment of perfect mental and bodily health. Not unfrequently, 
however, some peculiarities reveal themselves sooner or later in connec- 
tion with their nervous organism. They become more or less low-spirited 
or taciturn, or querulous, fidgety, or excitable; or there may be a little 
failure of memory, or some slowness of apprehension, or difficulty of appli- 
cation. The most remarkable mental phenomena, however, are those 
which are included in the term 'epileptic mania.' The attacks of mania 
resemble those which have been referred to as constituting a part of the 
epileptic paroxysm ; but they may occur independently of the epileptic fits 
and may last from a few hours or two or three days, to a week or two or 
more. They are remarkable, as a rule, for the suddenness of their inva- 
sion and the suddenness of their subsidence. They present two varieties 
which by Dr. Falret are termed respectively petit mal and haut mal. The 
latter is furious, attended with sudden attacks of uncontrollable violence 
and ideas and hallucinations of a terrifying character; the language of the 
patient is less incoherent than that of many other lunatics, and it is re- 
markable that each successive maniacal attack repeats the main features, 
in almost every detail, of the attacks that have gone before. In the petit 
mal the patient is morose and despondent, and mistrusts and fears those 
who are about him ; he is impelled, as it were, by some superior power, in 
obedience to which he performs acts that he would not otherwise do ; he 
leaves his home and occupation, wanders about, and is liable to sudden 
outbreaks of passion, in w r hich he will attack, destroy, or kill whatever 
comes in his way, or commit suicide. In both forms of mania the com- 
parative coherence of the patient might lead one to suspect that he was 
either malingering, or under the dominance of simple revenge or passion. 
Yet his memory of what has occurred in his attacks is exceedingly defect- 
ive; sometimes he recollects nothing; more often he recollects fragments 
of what has happened, as of a dream ; but he can rarely call to mind all 
that has taken place, and perhaps forgets the main incidents entirely. In 
some cases of epilepsy the patient's mind undergoes gradual deterioration, 
and he becomes imbecile or idiotic. It is said to be principally in the case of 
the petit mal that this result ensues. [This is probably due to the fact that 
the seizures are usually of much more frequent occurrence in the petit mal 
than in the haut mal; the number of times the fits are repeated apparently 
having more influence in the production of impairment of the mental 
powers than their severity.] In reference to this point, however, it must 
not be forgotten that epileptic fits are apt to supervene in cases of chronic 
madness, idiocy, and dementia. 

Epilepsy does not tend immediately to shorten the duration of life ; 
nevertheless, it materially increases the risks to life. The epileptic patient 
is liable to incur serious accidents: to fall into the fire and be burnt; to 
tumble into the water ; to be drowned while bathing; or to fall from his 
horse, or from a scaffolding, or over a precipice; he may also be choked 
when eating, or asphyxiated as he lies in bed. Very rarely the fit itself 
proves fatal without extraneous aid ; when it does, the patient dies from 



EPILEPSY. 



959 



asphyxia during its first stage, or from exhaustion or coma during the 
status epilepticus. 

From the multiform characters which epilepsy presents, its diagnosis is 
often a matter of extreme difficulty. When occurring only at night-time, 
it not unfrequently happens that the patient is ignorant of the nature of 
his malady or even that he has anything the matter with him. Yet, even 
in cases of this kind, a hint, or an admission, or the statement of some 
special occurrence may awaken the suspicions of the medical man. Thus 
the patient on waking up is uneasy, with giddiness, headache, or confusion 
of mind, from which he slowly recovers ; or he finds that his tongue is 
sore, and that there is blood upon his pillow ; or he notices petechial spots 
upon his face, neck, and chest ; or he finds that he has passed his evacua- 
tions into the bed, or that he has dislocated his shoulder, or otherwise injured 
himself. Now any of these accidents may occur independently of epi- 
lepsy; but if they recur from time to time, and especially if two or three 
be associated, the evidence in favor of epilepsy becomes very strong. 

The actual epileptic attack may be confounded with apoplexy or with 
hysteria. The true apoplectic attack, in which the patient falls down 
suddenly comatose, is now generally allowed to be epileptic or epileptiform. 
The point, therefore, to determine in such cases is not whether it be apo- 
plectic or epileptic, but what is the pathological condition on which the 
loss of consciousness depends. The distinctions between hysterical and 
epileptic fits are generally well-marked, and little doubt usually remains 
when the history of the case is obtained. Still the affections appear to 
run into one another, and the condition termed hysterical epilepsy forms 
the link between them. The main points to bear in mind in forming a 
diagnosis are (apart from the patient's history) the usually much greater 
violence and much longer continuance of the paroxysm of hysteria, the 
more general distribution of the convulsive movements, and the generally 
great and persistent noisiness of the patient. The hysterical patient, 
moreover, is seldom unconscious, can generally be roused without much 
difficulty, rarely bites her tongue, passes her evacuations into the bed, or 
injures herself; the skin, too, is hot, and the pupils act under the influ- 
ence of light. 

Few diseases are so frequently feigned as epilepsy. The coarser features 
of the haut mal are so striking that few persons can fail, with a little 
study, to imitate them fairly well. There are various points, however, 
about the real attack which the actor does not observe, or cannot copy. 
Thus he neither bites his tongue, nor passes his evacuations into his 
trousers ; his pupils are probably not dilated, and certainly not insensible 
to light; and his skin becomes hot and perspiring with his violent mus- 
cular exertions. Further, when he falls he takes care not to hurt himself; 
he overacts the convulsive part of the attack, but probably fails in details; 
moreover, he is alive to what is going on around him, takes furtive glances 
at the bystanders, and gives distinct evidence that he feels if he be hurt, 
or if a jugful of cold water be thrown over him. Still there may be real 
difficulty ; and it behooves the physician not to commit the error of assum- 
ing that a real epileptic is malingering. The stage which succeeds the 
period of insensibility is one not likely to be copied by a cheat ; yet it is 
a stage in which it is often not difficult to persuade one's self that the patient 
is shamming. 

Morbid anatomy and pathology There are few diseases about the 

pathology of which we are so entirely ignorant as we are about that of 



960 



DISEASES OF THE NERVOUS SYSTEM. 



epilepsy. It has been referred to anaemia of the nervous centres ; it has i 
been referred to hyperemia ; it has been assumed that the cerebral convo- 
lutions, the ganglia at the base, or the pons and medulla oblongata are 
mainly at fault; and the disease has been regarded as one involving the 
nervous centres as a whole. Morbid anatomy scarcely helps us ; for in 
the rare cases in which death has occurred in a fit, little or nothing more 
than hyperemia has been detected, with in some cases hemorrhage into j 
the perivascular sheaths of the smaller vessels ; and when chronic epilep- 
tics have been examined post mortem, either the brain has looked healthy, 
or it has appeared to have shrunk somewhat, or there has been some indu- 
ration of the white matter, or some thickening of the walls of the minute 
vessels with traces of previous hemorrhage in their vicinity. These 
lesions, however, have been mainly recognized in the brains of those whose 
epilepsy was associated with chronic insanity or dementia. Experiment 
has clearly shown that anaemia of the brain, suddenly produced, causes 
epileptiform convulsions; but, on the other hand, extreme congestion of 
the brain as occurs during the prolonged paroxysmal cough of pertussis is 
also followed by insensibility, associated with convulsive twitchings. 
There is every reason on clinical grounds to believe that in the epileptic 
paroxysm the brain is successively anaemic and congested. The extreme 
pallor which overspreads the surface at the commencement of the attack, 
and which has been observed, we believe, by Dr. Jackson to pervade the 
retinal vessels as well, may be taken as a clear indication that the brain 
itself is also anaemic at that time. And the great venous and capillary 1 
congestion which almost immediately afterwards replaces that pallor, ! 
coupled with the presence of post-mortem congestion and capillary hemor- 
rhages in the brain in fatal cases of epilepsy, show clearly that the early 
anaemic condition of the brain is soon succeeded by notable congestion. 
But, even if it be allowed that anaemia of the brain is the cause of the 
earliest epileptic phenomena, including the tonic spasms, it is obvious j 
that it is not the cause of the clonic spasms which come on with conges- 
tion. Dr. Marshall Hall, who clearly recognized this sequence, referred 
the clonic spasms to the congestion which followed upon the cessation of 
the respiratory acts, and recommended the performance of tracheotomy j 
with the object of preventing their supervention, and so of robbing the 
disease of its chief horrors. But if the epileptic phenomena depend on 
mere congestion or anaemia, this must obviously originate in some func- 
tional disturbance at the source of the vasomotor nerves which are dis- '] 
tributed to the cerebral vessels. 

The medulla oblongata and upper part of the cord are regarded by Dr. 
Reynolds as the primary seat of epilepsy. And MM. Luys and Voisin, as 
the result of careful post-mortem investigations, conclude that the parts 
which mainly suffer in this affection are the medulla oblongata, corpora 
striata, cerebellum, and other parts at the base of the brain. On the other 
hand, it has been shown by Brown-Sequard that epileptic convulsions may 
be artificially induced in guinea-pigs as a consequence of section of one of 
the lateral columns of the cord anywhere between the medulla and tenth 
dorsal vertebra. It must be admitted, indeed, that both tonic and clonic 
convulsions may be of spinal origin, and that in epileptic convulsions the I 
motor tract of the cord must necessarily be largely concerned; at the same 
time, from the special implication of the nerves at the base of the brain, 
there can be no doubt that the motor nuclei in the medulla oblongata and 
on the floor of the fourth ventricle and iter must be at least equally affected ; 



EPILEPSY. 



961 



further, from the general unilateral tendency of the spasms or predominant 
action of the muscles of one side when both sides are involved, there is 
great reason to suspect that, however much the various nuclei of the motor 
tract are involved, they are dominated by the corpus striatum. Still, 
when we look to the clinical facts of epilepsy, and recollect that convulsion 
is by no means the most frequent or the most important element of the 
attack, and that when it occurs it is usually preceded by some aura, sen- 
sation, spasm, or hallucination, and is attended from the beginning either 
with absolute loss of consciousness or with a dreamy condition in which 
there is often a total insensibility to external impressions, it is impossible 
not to acknowledge : that, however seriously the cord, medulla, and gan- 
glia at the base of the brain may be implicated subsequently, the earliest 
phenomenon must be connected with some limited spot in the nervous cen- 
tres, which, though different for different cases, is probably always the 
same for the same case; that the pain, sensation, giddiness, or hallucina- 
tion, is probably of central origin ; and that from this primarily affected 
spot a sudden influence is discharged over the sensorium and the sensori- 
motor regions of the cerebrum, which as regards the sensorium either 
annuls consciousness wholly or in part, or perverts it, and as regards the 
motorial system, either excites it to unwonted or perverted action, or 
arrests its operations. There is reason, therefore, to believe that the epi- 
leptic fit commences before the brain becomes anaemic, and room, there- 
fore, to question whether this anaemic state of the brain is the cause or the 
consequence of the symptoms which accompany it. There is equal reason, 
we think, to doubt, whether the congestion which follows the anaemia is 
the cause of the clonic contractions and of the various phenomena which 
attend their occurrence ; and whether, finally, the after-symptoms are to 
be referred (as some suppose) to carbonic acid poisoning. The pathology of 
the affection is, we repeat, obscure, and we do not attempt to elucidate it. 

Treatment — During the epileptic attack there is usually little to be done 
beyond preventing the patient from injuring himself, and removing all 
sources of pressure from his neck. It is often well to prevent him trom 
biting his tongue by inserting a pad between his teeth. Convulsions may 
often be allayed by the inhalation of chloroform ; and it may be advisable,, 
when the congestion of the face is extreme and long-continued, to remove 
blood from the distended vessels of the neck. Not unfrequently, when 
the attack is preceded by a warning of sufficient duration, it may by proper 
management be averted. Among measures which have been successfully 
adopted for this purpose are : the inhalation of chloroform or ammonia, the 
administration of a dose of sal-volatile or ether, the application of a liga- 
ture above the point from which the aura springs, or the forcible preven- 
tion of the closing of the fingers or the flexion of the arm, when such 
movements constitute the premonitory symptoms. Latterly Dr. Crichton 
Brown has, for the same purpose, had recourse, with success, to the inhala- 
tion of nitrite of amyl. 

The measures which have been employed to cure epilepsy are innumer- 
able. Many drugs have been administered with more or less success, 
among which may be enumerated the sulphate and oxide of zinc, arsenic, 
copper, iron, nitrate and oxide of silver, and the bromides of potassium 
and ammonium ; belladonna, digitalis, strychnia, opium, and Indian hemp ; 
as also musk, valerian, and assafbetida. The list might easily be extended. 
Of the above, those which have perhaps enjoyed the widest reputation are 
the salts of zinc, silver, and arsenic, belladonna, and the bromides of potas- 
61 



962 



DISEASES OF THE NERVOUS SYSTEM. 



sium and ammonium. Belladonna has been strongly advocated by Trous- 
seau, who recommends that it be given in the form of a pill containing ^ 
grain each of the extract and powdered leaves ; or that in its place the 
of a grain of the sulphate of atropia be administered. He recom- 
mends that during the first month one of the pills be given daily, and that 
a pill per month be added, until the daily allowance of pills amounts to 
from five to twenty. He strongly urges that the pills be given either night 
or morning, according as the fits are nocturnal or by day, and invariably 
at the same hour in the same case. Bromide of potassium has been the 
favorite remedy of late years, and there is no doubt that its use is often 
highly beneficial and sometimes curative. The dose should vary from 10 
to 30 grains three times a day, and it should be given for a considerable 
length of time. But probably more important than medicine is careful 
attention to hygiene ; the patient's habits should be ascertained, and, if in 
fault, corrected; masturbation and excessive venereal indulgence should 
be checked ; over-eating, and especially over-drinking, late and irregular 
hours, and excitement of all sorts should be avoided. He should live 
quietly, keep good hours, take nourishing wholesome food, eschew alcohol 
as far as possible, attend to the condition of his evacuations, and, if need 
be, have change of air and scene. It is often a question whether the 
patient should give up work — whether if a man he should cease to engage 
in his ordinary business pursuits, if a child, give up learning. The answer 
to such questions must depend on the special circumstances of the case. 
No doubt when the fits are severe and frequent, it may be well to cease at 
least for a while from all mental labor and sense of responsibility ; but in 
the great majority of cases there is every reason to believe that a certain 
amount of mental occupation, and it may be added of bodily exercise, is 
beneficial to the patient, and that, on the other hand, entire cessation from 
work is injurious. As a rule, therefore, the child should pursue his stu- 
dies, the adult his usual avocations ; but neither should be allowed to push 
his work to excess. Lastly, counter-irritation, setons and issues behind 
the neck, shower-baths, cold baths, and ice along the spine, and even the 
removal of the clitoris or of the testicles have each had their special advo- 
cates. There are no sufficient grounds, however, for believing any one of 
these measures to be really beneficial. 

B. Eclampsia. 

Definition and causation This is the name which is now commonly 

applied to all those varieties of epileptiform convulsions which occur acci- 
dentally, so to speak, in dependence on some specific lesion or the presence 
of some special pathological or physiological process. Eclampsia may be 
one of the phenomena consequent on fracture of the skull, effusion of 
blood into the brain, or obstruction of a cerebral artery ; it may be de- 
veloped in connection with the growth of an intracranial tumor, whether 
this be tubercular, syphilitic, carcinomatous, hydatid, aneurismal, or other ; 
it is liable to occur when there has been sudden and copious loss of blood, 
when the brain is deeply congested, or when certain poisons circulate with 
the blood — it thus attends poisoning by hydrocyanic acid or absinthe, the 
retention of effete matters in the blood from renal disease, and in young 
children is often one of the earliest indications of the operation of the scar- 
latinal poison, or that of other infectious disorders ; further, it is often 
induced by reflex action, and thus sometimes occurs during parturition, 



INFANTILE CONVULSIONS. 



963 



and in children is a frequent consequence of teething, gastro-intestinal dis- 
turbance, and many slight local conditions which in older persons would 
cause little or no inconvenience. 

Symptoms and progress.-*— The fits of eclampsia are not distinguishable 
from those of true epilepsy. They may be exceedingly slight, they may 
be robbed, as it were, of one or more of the recognized stages, or they may 
present in a typical form all the sequence of events characteristic of the 
haut mal. But they are often less sudden in their invasion ; the patients 
are less liable to lose consciousness absolutely than true epileptics are ; the 
fits much more frequently have a fatal issue, either from coma or from ex- 
haustion ; and they are much more irregular in their occurrence — probably, 
however, becoming more and more frequent and severe if the affection on 
which they depend is a progressive one, or ceasing permanently if their 
cause is removed. Further, with the exception that children who have 
eclampsia sometimes become epileptic in after life, these accidental fits 
seldom or never merge into true epilepsy. The diagnosis of these cases 
must depend less on the phenomena of the attack than on their history and 
the circumstances which attend them — such as the presence of constitu- 
tional syphilis, the existence of renal disease, the fact that symptoms of 
cerebral disorder have been gradually creeping on before the convulsions 
attacked the patient, the evidences of abundant loss of blood, the progress 
of parturition, and the like. 

Treatment The treatment of eclampsia will depend mainly on the 

diagnosis at which we arrive ; thus syphilitic eclampsia will need to be 
treated with iodide of potassium and mercury .; renal eclampsia will prob- 
ably demand the use of powerful drastic purgatives ; anaemic eclampsia will 
call for good nourishment and stimulants , eclampsia arising from accidental 
causes of irritation will require the removal of these causes ; while that 
variety which is connected with progressive cerebral disease can only be 
treated by palliative measures. 

C. Infantile Convulsions. 

Definition and causation. — These are rarely epileptic in the true sense 
of the term, and come therefore properly under the head of eclampsia. 
There are reasons, however, for giving a separate brief consideration to 
them. 

Convulsions arise in young children, especially during the time of teeth- 
• ing, with remarkable readiness and frequency ; and indeed Dr. West ob- 
serves that convulsions in children seem often to take the place of delirium, 
or rigors, in adults. It is certain that they are very often developed in 
the course of diarrhoea and other disorders of the gastro-intestinal tract ; 
that they occur in bronchitis and other affections of the respiratory appa- 
ratus ; that they come on not only at the period of invasion of scarlet fever 
and other like diseases, but that they may be induced in the course of 
these disorders by various accidental circumstances ; that they often depend 
on mere innutrition or anaemia; that they are common in rickety children; 
and that they are peculiarly liable to occur in connection with the irrita- 
tion of teething. Children are, of course, liable, as adults are, to convul- 
sions in the course of the development of tumors or other diseases of the 
brain or its meninges. 

• Symptoms and progress The convulsive attacks of children do not 

differ essentially from those of adults. They may be equally numerous, 



y64 



DISEASES OF THE NERVOUS SYSTEM. 



equally violent, and the 'status epilepticus' may be equally developed. 
They vary alstf in their intensity between the wildest extremes. They do 
not, therefore, need any special description. Slight fits or threatenings of 
fits are very often indicated, either when the child is awake or when he is 
asleep, by sudden spasm of one or both hands with turning inwards of the 
thumb upon the palm, or by a momentary fixedness in the child's look, 
attended probably with pallor, dilatation of pupils, squinting, or some con- 
vulsive twitches of the face or limbs. It not unfrequently happens in 
children that the incidents of the fit are mainly connected with spasmodic 
contraction of the glottis and respiratory muscles. Respiration suddenly 
ceases, the face becomes livid and bloated, the veins swell, there is some 
rolling of the eyes, some convulsive movements of the muscles of the face ; 
then the head falls upon the chest, and the limbs become flaccid, the pulse 
gets feeble, quick, and perhaps imperceptible, bloody sputum issues from 
the mouth, copious sweats break out, and if respiration be not speedily 
restored death ensues. In some instances such attacks are ushered in with 
a kind of crowing inspiration (laryngismus stridulus) ; in many they are 
perfectly silent. They are sometimes brought on during the continuous 
holding of the breath, or continuous expiration, which occurs when the 
child begins to cry, or when he is coughing or about to cough, and espe- 
cially in connection with the paroxysmal attacks of hooping-cough. The 
number of fits which children suffer from and the frequency of their recur- 
rence vary greatly. Sometimes the child has a single fit, and never any 
more ; sometimes the fits recur many times a day, and the child may ex- 
perience many hundreds of them in the course of a year. Not unfrequently, 
as before stated, he may pass into the status epilepticus and remain in that 
condition for some hours or even a day or two. Infantile convulsions are 
always, and on good grounds, a matter for serious alarm ; it is astonishing, 
however, how children will suffer from almost innumerable fits occurring 
off and on for months and years, and yet recover perfectly. On the other 
hand, they are often fatal. The most dangerous are those which chiefly impli 
cate the respiratory organs, and those which by their rapid succession 
render the child comatose for a long period. The immediate cause of 
death is either suddenly or slowly induced asphyxia, asthenia, or coma. 
Fits often repeated have, in some instances, similar results to those occur- 
ring in adults ; they are sometimes followed by more or less permanent 
hemiplegia or some other form of paralysis, or by failure of intelligence or 
idiocy. Stammering, squinting, and other such defects are sometimes at- 
tributed to fits in early life. 

Treatment. — The child's general health must be carefully maintained 
or improved ; all affections, all causes of irritation which are present, must 
be removed. Bronchitis must be cured, diarrhoea checked, irritability of 
the stomach assuaged; if the gums are congested and swollen, and the 
child is evidently suffering in consequence, they should be freely lanced, 
and the operation should be repeated whenever the indications of irritation 
return ; if the child has been having unwholesome or insufficient food, or 
if he has been over-fed, these conditions must be obviated. The various 
specific modes of treatment are as applicable in the case of young children 
as in that of adults ; 'and hence belladonna, bromide of potassium, anti- 
spasmodics, and other remedies have all been recommended, and in certain 
cases have been found serviceable. In the fit itself, there seems no reason 
to object to the ordinary practice of putting the child into a hot bath, and 
applying cold water or a sponge dipped in cold Avater to his head or face. 



HYSTERIA. 



965 



Chloroform inhalations may also be had recourse to. Fits may sometimes 
be averted by applying ammonia to the nose, or cold water to the face, at 
the moment of their commencement, or when premonitory symptoms are 
heralding their approach. 



XIV. HYSTERIA. 

Definition It is difficult to describe, still more difficult to define, 

hysteria. It may, however, in general terms, be said to be a functional 
disorder of the nervous system, occurring mainly in females from the age 
of puberty upwards, in which the will, the intellect, the emotions, sensa- 
tion, motion, and the various functions which are under the influence of 
the nervous system, are involved, or apt to be involved, in a greater or 
less degree. 

Causation. — As has already been stated in the definition of the dis- 
ease, hysteria principally affects females and usually makes its appearance 
in them for the first time between the age of commencing puberty and that 
of five-and-twenty. It may come on, however, previous to puberty, and at 
any age after twenty-five ; but in the latter case more especially about the 
time of the cessation of the menses. Males occasionally become distinctly 
hysterical ; but there does not appear to be the same tendency in them as 
in women for the disease to come on in early life. The causes of hysteria 
like those of so many other functional nervous disorders, are very obscure. 
There are two or three, however, which seem to have a very important in- 
fluence, direct or indirect, in its causation ; these are emotional disturbance, 
sexual conditions, and occupation. 

Nothing is more certain than that hysterical phenomena and the hysteri- 
cal fit itself are frequently induced by circumstances which affect the emo- 
tions powerfully, such as sudden fright or horror, powerful religious impres- 
sions, disappointed love or hope deferred, grief, jealousy, and the like. 
And, indeed, in those who are strongly predisposed to the affection, the 
most trivial disturbances of this kind are liable to provoke violent out- 
breaks. Hysteria, like chorea and epilepsy, is often contagious. 

The name hysteria was given to the disease under consideration in the 
belief that the womb was its seat. The fact that it occurs amongst men 
shows that that view of its origin cannot, at least in all cases, be correct. 
As regards females, however, there can be no doubt that the reproductive 
functions or organs do exercise a greater or less influence over its pro- 
duction. It comes on usually about the period of puberty or that of the 
climacteric change. Though not by any means occurring only in unmar- 
ried women, and those who are unhappily married, it occurs in them much 
more frequently than in such as become the happy mothers of families. 
And, again, in no inconsiderable number of cases, there is distinct evi- 
dence of involvement of one or both ovaries in the facts that they are 
painful to pressure and that characteristic hysterical symptoms may be 
induced by applying strong pressure to them. There is, however, no 
necessary connection between the condition of the catamenial flow and 
hysteria, although it must be admitted that the catamenia are often at 
fault in hysterical women, and that occasionally their restoration to the 
normal condition is attended with the restoration of the patient's general 



966 



DISEASES OF THE NERVOUS SYSTEM. 



health. Nor is there sufficient ground for believing that the mere default 
of sexual congress either in the male or in the female has, as a rule, any 
important influence in its causation ; excepting, perhaps, in so far as it 
may be connected with the yearning for love, the sense of neglect, jealousy, 
and other such feelings. Sexual excesses, and especially masturbation, 
have been assigned as causes. 

There can be little doubt that occupation and position in life have 
something to do with the production of hysteria ; for it is a disease which 
affects the higher classes in a disproportionate degree ; but, if these con- 
ditions are concerned in its causation, it is owing to the accidental fact 
that wealth brings with it the needlessness for work and the capability of 
indulgence in frivolous amusements and idleness, with consequent neglect 
of the healthy exercise and discipline of the mind. Other causes which 
have been assigned for hysteria are hereditary predisposition, overwork, 
anaemia, debility, and other forms of failure of health ; but any influence 
they may exert is at best remote. 

Symptoms and progress In describing the clinical phenomena of 

hysteria, we will first discuss the mental characteristics of those who 
suffer from it, and then consider seriatim the various motor, sensory, and 
sympathetic disturbances which are apt to be associated with them. 

The mental conditions of hysterical patients present the greatest variety, 
and yet there are gradations between the extreme conditions which prove 
their relationship. In many cases, women, who are liable to hysterical 
attacks under occasional states of ill health or excitement, are, in the 
intervals between their attacks, as healthy in body and mind, and as free 
from all caprice or peculiarities of temper, as we could wish to see them. 
They will often acknowledge, however, that, at the moment when hysteri- 
cal feelings come upon them, they feel compelled to yield to them, and 
indisposed to make any effort to restrain them ; and that yet, if anything 
occurs to incite them to use self-control, they are able to resist them suc- 
cessfully. In other cases the patient is nervous and excitable, with little 
control over either her emotions or her actions, apt to laugh or cry on the 
slightest provocation and incongruously, and apt also to suffer from time 
to time from the various complications of hysteria. But, in a very large 
proportion of cases, the whole moral character of the patient is more or 
less profoundly altered. She is apathetic and neglectful of her duties, or 
exacting, selfish, and suspicious, exaggerating all her trivial annoyances 
and discomforts or disorders, resenting all healthy advice or reasonable 
attempts to promote her welfare, and quarrelling therefore it may be with 
her husband or dearest friend, but pouring out profuse affection on all 
those acquaintances, however new they may be, who affect to pity her 
condition, make the most of her ailments, and adapt themselves to all her 
changing moods and caprices. Under such circumstances it is astonishing 
to see women, well nourished, and apparently in the best of general bodily 
health, remain for months and years useless members of society, suffering 
from paralyses and other maladies which they profess to look upon with 
the utmost alarm (and which they declare perhaps to be family com- 
plaints), not only with quiet complacency, but with a studied resistance 
to all plans of treatment likely to be of service to them. They are prob- 
ably only too willing, however, to put themselves into the hands of some 
fashionable charlatan, or to do anything else which will render their mis- 
fortunes in any degree notorious. It is but a step from hugging her 
ailments and exaggerating them to malingering. And although we cannot 



HYSTERIA. 



967 



fairly accuse the great majority of hysterical patients of shamming, sham- 
ming is by no means uncommon. The craving for pity and notoriety in- 
creases by being fed ; the greater the commiseration she excites, the more 
does she endeavor to be worthy of it, and the more serious become the 
ailments from which she is suffering ; and soon perhaps new phenomena 
develop. It is an interesting and important fact that the nature of these 
phenomena is not unfrequently determined by the direction which the 
interest and solicitude of the doctor or friends happen to take. If they 
pity her failing appetite, she soon perhaps affects to live without food ; if 
it be observed that her urine and motions are scanty, she finds before long 
that they cease altogether ; if it be a matter of wonder or speculation what 
becomes of her evacuations, she will be found perhaps to vomit urine or 
feces, or blood. It is by such persons, though not by these alone, that 
various other forms, more or less singular, of malingering are practised. 
Thus at one time a patient will bring on hard oedema or spurious 
elephantiasis of the arm or leg by the constant application of a ligature 
round the upper part of the limb, and will even submit to its amputation ; 
at one time she will, by the constant application of some irritant sub- 
stance, fret her skin into ulcers, and thus even cause perforation of the 
stomach ; at one time she will place lumps of coal up her vagina, and 
pretend that she is suffering from vesical calculus ; at one time she will 
affect to have communion with the Virgin Mary, to have the marks of 
the stigmata on her hands and feet and side, and at the same time, prob- 
ably, to live devoid of all those natural appetites and wants which are 
inherent in mortality. Hysterical patients sometimes suffer from a form 
of insanity known as hysterical mania ; and occasionally after the lapse of 
years pass into a state of dementia. 

We will now proceed to describe the various phenomena which are so 
apt to go along with the mental states which have just been considered, 
and which form, as a rule, the more striking phenomena of hysteria. 

1. Convulsions and spasms Hysterical convulsions vary in their sever- 
ity and duration, and have a more or less general resemblance to those of 
epilepsy, from which, however, it is important to distinguish them. The 
patient is rarely attacked without warning. She has probably, for some 
little time previously, been suffering from hysterical symptoms ; she has 
been laughing, crying, or sobbing, or talking wildly or gesticulating vio- 
lently, or she has complained of a sense of constriction or of a ball in the 
throat, or has manifested, in a marked way, some of the mental or emo- 
tional phenomena which are characteristic of hysteria. Then suddenly, 
perhaps, she utters a loud scream, and falls upon the sofa or the ground 
violently convulsed. The fit may last for a few moments, or be prolonged 
for a quarter of an hour, or continued by successive attacks for many hours, 
interrupted from time to time by cries, and sobs, and laughter. Such 
phenomena generally also attend the subsidence of the attack; or, if the 
patient be worn out with her long-continued exertions she falls into a sound 
sleep. The main features by which the hysterical fit may be distinguished 
from the epileptic are the following : the hysterical patient, no matter how 
severe her attack may be, is very seldom totally unconscious; she can 
generally be roused either by the voice of authority, or a douche of cold 
water ; she is noisy — the epileptic utters a single cry, or none at all, while 
the hysterical patient probably screams and cries and laughs and groans, 
or talks volubly and incoherently off and on during the whole of her attack ; 
her convulsions are much more general and extensive than those of the 



968 



DISEASES OF THE NERVOUS SYSTEM. 



epileptic — she throws her arms and legs about in all directions, she twists 
her body into the most grotesque attitudes, she suddenly raises herself to 
the sitting posture, and then throws herself violently down again, but with 
all this violence and excess of muscular effort she rarely, if ever, injures 
herself ; the convulsions are rarely tonic at any period of the attack ; they 
are rarely, if ever, unilateral, and the face (unless when the patient is cry- 
ing out) is free from the hideous distortion of epilepsy ; she does not bite 
her tongue ; the eyelids are closed and tremulous, but the pupils respond 
to light, and there is no tendency to squint ; respiration never ceases, but 
is from the beginning noisy and irregular, and consequently, although the 
skin may become hot and perspiring, the patient never presents that livid- 
ity of countenance which attends the true epileptic attack ; she does not 
discharge the contents of her rectum and bladder; and lastly, if we in- 
vestigate the history of the patient, we never find that she suffers from 
attacks of the petit mal or epileptic vertigo. Yet, though the distinction 
between epilepsy and hysteria is for the most part easy, instances are 
sometimes met with in confirmed and severe cases, in which the hysterical 
attack puts on some of the features of epilepsy. It is then attended with 
sudden and total unconsciousness, and it may be with tonic spasm, tempo- 
rary arrest of respiration, lividity of face, and biting of the tongue ; but 
even here the antecedent presence of the globus hystericus and other indi- 
cations of hysteria, and the ultimate conversion of the attack into one of 
obvious hysteria are generally sufficient to render diagnosis easy. Charcot 
points out as a further distinction between these attacks and those of true 
epilepsy, that they never lead to impairment of the intelligence or demen- 
tia ; he further points out as an important distinction between the status 
epilepticus and the corresponding condition in hysteria, that in the former 
case the temperature rises to 103° or 104° or more, while in hysteria it 
rarely exceeds the normal by more than one or two degrees. 

But besides these general convulsive attacks, hysterical patients are 
liable to permanent or tonic contractions of groups of muscles or limbs. 
These, as will presently appear, are not unfrequently associated with paraly- 
sis. Among them may be mentioned spasmodic closure of the hands, 
trismus, and spasmodic contractions at the knee or other joints. 

2. Hyperesthesia is exceedingly common among hysterical women. It 
may be general, or hemiplegic, or paraplegic, or it may affect a limb or a 
joint, the mamma or the ovary, the spine, or indeed any part of the surface, 
or any organ. Pain varies in its severity, is sometimes induced only by 
pressure, but often occurs independently of all external sources of irritation. 
It is a curious and suggestive, but not invariable, characteristic of it, that 
the patient will shrink from the slightest touch when she is expecting it, 
and yet will allow the painful part to be compressed and handled violently 
when her attention is directed to other matters. A common pain of which 
hysterical women complain is that which is termed clavus ; it is generally 
referred to the forehead just above the eyebrow, and is likened to the effect 
of a nail driven into the skull. The most interesting variety of hyperes- 
thesia, however, is that of which the globus hystericus forms a part. The 
globus hystericus is a sensation as of a ball rising into the throat and im- 
peding respiration ; it is of frequent occurrence in hysterical patients, and 
is commonly present before and during paroxysmal attacks. It often seems 
to spring from the iliac fossa. The patient then complains of pain or ten- 
derness on pressure in this situation, whence from time to time the hyster- 
ical aura, as it may be termed, seems to spread : first to the epigastrium, 



HYSTERIA. 



969 



causing nausea and vomiting ; then to the chest, provoking violent action 
of the heart and palpitation ; then to the neck, constituting the globus 
hystericus, which is often associated with sobbing, choking, and other such 
symptoms ; and thence finally, according to M. Charcot, to the head, when 
it induces noises in the ears, dimness of vision, and clavus, all on that side 
of the body from which the aura started. These phenomena constantly 
precede the occurrence of the hysterical fit, and, according to the older 
writers, with whom M. Charcot is completely in accord on this point, are 
referable to some peculiar condition of one or other ovary, generally the 
left. He states: that in a large number of hysterical women there is a 
tender point which may be discovered on deep pressure made directly 
backwards at the point of intersection of the horizontal line drawn between 
the two antero-superior iliac spines, and the continuation downwards of the 
vertical line which marks the lateral boundary of the epigastrium ; that 
this point represents the ovary, which may, in fact, when the abdominal 
walls are flaccid, be often distinctly felt in this situation ; and that con- 
tinued pressure upon it will induce all the phenomena above described of 
the hysterical aura. This iliac or hypogastric pain varies in severity ; in 
many cases it can only be discovered by hunting for it ; but in many ex- 
treme pain and tenderness, so great as to forbid the slightest pressure, 
occupy not only the ovary but the superposed muscles and skin ; and occa- 
sionally these phenomena become so widely diffused as to simulate the local 
symptoms of peritonitis. Intolerance of light, intolerance of sound, and 
intolerance of certain sapid or odorous substances, often associated with 
extreme acuteness of the special senses, is very common in hysterical 
women. But here again the phenomena generally present that marked 
characteristic of hysteria, namely, that the patient will complain bitterly 
of the slightest impression when her mind is directed towards it, but will 
endure the most discordant sound or the brightest light when her attention 
is distracted by other objects. 

3. Anaesthesia is frequent among hysterical persons. It may occur in 
various parts of the body, and be limited to the distribution of a single 
nerve ; it may affect the sense of smell, or taste, or may implicate the eye, 
causing dimness of vision or difficulty in recognizing colors. The most 
remarkable cases, however, are those of hemianaesthesia, with or without 
coexisting loss of motor power. In this variety the loss of sensation as a 
rule involves uniformly the whole of one side of the body — leg, trunk, 
arm, and head and neck — ceasing abruptly at the median line ; and it in- 
volves not merely the skin, but the mucous membrane of the mouth and 
the organs of sense, so that taste and smell are lost upon the affected side, 
and the eyesight probably fails. Further, it usually implicates the deeper- 
seated tissues as well, namely, the muscles, bones, and joints. It may be 
complete and profound, or it may be merely insensibility to pain, with or 
without insensibility to variations of temperature. The anaesthetic parts 
are usually pale, and their temperature more or less considerably reduced. 
Hemianesthesia is apt to come and go, and occasionally shifts to the op- 
posite side of the body. Sometimes the anaesthesia becomes bilateral. 

4. Paralytic conditions are probably the most common of the complica- 
tions of hysteria. Like anaesthesia, paralysis may affect any part ; it may 
involve the hand, the forearm, the entire upper extremity ; it may affect 
the leg or same part of it ; in some case it assumes the form of paraplegia, 
in some that of hemiplegia ; or it may be irregularly distributed, or gene- 
ral. It seldom implicates the muscles of expression. The paralysis may 



970 



DISEASES OF THE NERVOUS SYSTEM. 



be complete or incomplete. The affected limb or limbs may be flaccid or 
rigid. Faradic contractility remains for the most part unimpaired, but 
electric sensibility of the muscles is generally more or less completely lost. 
The muscles usually do not waste. In the majority of cases hysterical 
paralysis may be distinguished from other forms of paralysis with tolerable 
readiness, but not always. 

If the paralysis be hemiplegic, it comes on probably after an hysterical 
fit ; it involves the arm and leg, but neither the tongue nor the face ; the 
affected limbs are probably rigid — the arm bent, the hand firmly closed — 
while the lower extremity, on the other hand, is extended — the toes 
pointed, and the limb and pelvis movable only in mass ; it may be that 
the arm is flaccid while the leg is contracted, or conversely ; the paralysis 
is probably associated with hemianesthesia. [The gait of the hysterical 
patient is so peculiar, that an experienced physician will rarely be misled 
by it into thinking that the apparent loss of power is really due to organic 
disease. Upon closely watching her movements it will be observed that 
she always drags her foot and makes no effort to use it. The true para- 
lytic, on the other hand, while she supports herself on the sound limb uses 
the muscles of the hip of the other side — which usually regain power 
sooner than those lower down — and by their aid swings the foot round to 
a position in front of the other, thus causing it to describe a semicircle.] 
It may be remarked that the hemiplegia of organic brain-disease is only 
occasionally associated with complete hemianesthesia ; that it is never 
attended with persistent rigidity from the beginning ; and that if in this 
case there be any difference between the arm and leg in this respect, it is 
the arm and not the leg which becomes rigid. If the paralysis be para- 
plegic, the limbs are usually rigid and in a condition of extension ; and 
the paralysis with rigidity is probably, as in the other case, suddenly 
developed. 

Whether the paralysis be hemiplegic or paraplegic, or limited to a limb 
or part of a limb, it is apt to come and go, and to shift from limb to limb, 
or to involve more or less suddenly other limbs besides those first affected ; 
and, above all, it is generally associated with other phenomena indicative 
of the presence of hysteria. It is important, however, to recollect : that, 
although hysterical paralysis generally presents variations in degree, in 
character, and in site, it is (especially in its hemiplegic or paraplegic form) 
liable to continue for years or for life ; and that although as a rule the 
muscles remain unaffected as regards their bulk and contractility, they 
may, in cases of long standing, undergo degenerative changes from disuse, 
in connection with which secondary lesions may also take place in the 
cord. 

5. Affections of the larynx and air-passages. — Aphonia is very com- 
mon; the patient loses her voice completely and speaks only in the 
feeblest whisper ; she probably, however, has no soreness in the throat, 
no difficulty or pain in swallowing, no evidence whatever of local disease. 
The voice, moreover, is generally feeblest when the patient is asked to 
display her powers ; and sometimes reappears with sudden force under the 
influence of momentary excitement or it may be of forgetfulness. In some 
cases there is actual dyspnoea, which becomes so extreme as to demand 
operative procedure. Attacks simulating those of ordinary asthma are 
occasionally observed. Not unfrequently a peculiar cough, which Sir 
Thomas Watson describes as 'loud, harsh, dry, more like a bark, or a 
hoarse bleat, than a cough,' is one of the special phenomena of hysteria ; 



HYSTERIA. 



971 



it is apt to come on in paroxysms, which may continue for hours without 
cessation, and may come on daily or nightly for weeks or months. In 
some cases, without apparent cause, and with a pulse but little exceeding 
the normal rate, the respirations will suddenly rise to 40, 50, or even 70 
or 80 in the minute, and continue thus for some minutes, or on and off for 
hours, and yet without other evidence of dyspnoea or distress. 

6. Affections of the alimentary canal. — In some instances patients 
suffer from well-marked trismus, which interferes seriously with both 
speaking and eating; occasionally they complain of difficulty of degluti- 
tion ; and distension of the stomach, with rumbling and eructations, is of 
common occurrence. Hysterical patients often suffer from vomiting, and 
in some cases this constitutes the most serious part of their malady; the 
vomiting is apt to come on after every meal, or it may be at some particu- 
lar time of the day, and to be continued day after day for months or 
years. This sickness is frequently associated with good or even voracious 
appetite; but the bulk of matters vomited often seems in excess of the 
ingesta, and after a time extreme emaciation and debility probably ensue. 
In some instances the symptoms almost accurately resemble those due to 
ulcer of the stomach. The bowels are usually constipated, and there may 
be more or less pain in defecation. 

7. Affections of the urinqry organs Retention of urine often occurs. 

Doubtless it sometimes depends on paralysis of the bladder, contraction of 
the sphincter, or pain in the act of micturition ; but not unfrequently, like 
other hysterical conditions, it is more or less within the control of the 
patient, who makes no attempt to relieve herself voluntarily so long as she 
can enjoy the morbid pleasure of having the catheter passed for her. But 
more interesting than this are the phenomena connected with the secretion 
of urine. It usually happens, after an hysterical tit, or after other parox- 
ysmal nervous disorders, that the patient excretes large quantities of pale 
limpid urine. And such profuse discharges are not unfrequent at other 
times. But the opposite condition may be present. The patient consecu- 
tively for many days does not pass more than a few ounces of urine. In 
a remarkable case published by M. Charcot, the sufferer, a woman, forty 
years old, for more than a couple of weeks passed every other day only 
five grammes of urine, and none on the intervening days, and for a con- 
tinuous period of ten days secreted no urine whatever. During one month 
her average daily yield was only three grammes, and during another 
month only two grammes and a half. In this case the diminution and 
suppression of urine were unconnected with renal disease, but were asso- 
ciated with constant vomiting, the quantity of fluid vomited having some 
supplementary relation to the quantity of urine voided. Further, the 
vomit contained urea, yet the urea secreted daily by the kidneys and 
stomach together was very far indeed below the normal. For a period of 
twelve days it amounted from both these sources to only five grammes 
daily. M. Charcot remarks, in reference to such cases, that the escape of 
even a small quantity of urea in calculous obstruction of the ureters often 
serves to ward off dangerous symptoms, and that doubtless the same rule 
applies here; but he further observes that there is probably in hysterical 
ischuria an impairment of the functions of assimilation which diminishes 
the total amount of urea and extractives to be discharged from the body. 

8. Of affections of the reproductive system little remains to say beyond 
what has already been said. Amenorrhoea, menorrhagia, and other men- 
strual disorders are no doubt frequent accompaniments of hysteria ; but 



972 



DISEASES OF THE NERVOUS SYSTEM. 



many hysterical women are quite free from them. Again, the hyperes- 
thesia which is so common in various parts of the body in hysteria may 
affect the vulva or vagina and render the act of coition intolerable ; whilst 
on the other hand, lascivious feelings are occasionally strongly developed, 
and either induce in the patient a demeanor, probably towards certain 
individuals, which far transgresses the bounds of womanly self-respect, or 
give a motive for feigning disease of the sexual organs. It is not sur- 
prising that the mental obliquity of such patients should occasionally 
incline in this direction. 

9. Other affections which hysterical patients are apt to mimic are 
those of the spine, of the joints, and of the mammce. These have already 
been adverted to under the head of hyperesthesia. It need only be added 
that they often closely simulate inflammatory disorders of the same organs, 
and are apt to be mistaken for them; and that we must not hastily assume 
that a suspected hysterical affection of these parts is not hysterical because 
we discover, in addition to pain and tenderness, more or less swelling. 

10. Spinal irritation is the name which has been given to a group of 
hysterical phenomena which have been particularly described by Mr. Teale 
and the Messrs. Griffin, and is still by many regarded as a distinct affec- 
tion. It is characterized by the presence of more or less considerable 
tenderness at some spot in the course of the spine, or more rarely generally 
throughout its whole length, and by pain or other nervous phenomena re- 
ferred to those parts of the body whose sensory nerves are in relation with 
the tender spot, or to certain of the viscera. Moreover, pressure upon the 
tender spot aggravates, or it may be actually induces, the phenomena in 
question. If the tenderness occupy the upper part of the cervical spine, 
the neuralgic pain associated with it affects the occipital region, or it may 
be even the distribution of the trifacial ; if it be a little lower down, the 
neck suffers; if it occupy the situation of the cervical enlargement the 
pain is experienced mainly in the arms ; if it be present in the dorsal 
region then the parietes of the chest or abdomen suffer ; if it implicate the 
lumbar enlargement, the pelvis and the lower extremities are the chief 
seats of pain. Further, the sensation of a lump in the throat, palpitation, 
dyspnoea, spasmodic cough, gastralgia, nausea and vomiting, irritability of 
the bladder, or suppression of urine are all apt to attend the spinal tender- 
ness ; but the particular group of these complications appears to be deter- 
mined, like the neuralgic pains, by the situation of this tenderness. In 
all respects besides those which have been enumerated, the symptoms 
which the patients present are identical with those of other forms of hys- 
teria, and indeed the phenomena of these affections are, if not common to 
both, inextricably interwoven. The course of the disease, moreover, is 
identical in all respects with that of hysteria. 

The diagnosis of hysteria is not always easy ; and yet if the patient be 
carefully watched from day to day it is difficult to remain very long in 
doubt. It is not, however, an unnecessary caution to remind the reader 
that not only does hysteria ape many diseases so as to be readily mistaken 
for them, but that other diseases often simulate the phenomena of hysteria 
and may be easily taken for it. There is always a great temptation to 
assume that nervous disorders which we do not understand, and obscure 
visceral affections, in females are hysterical. Among diseases which may 
thus be mistaken for hysteria should especially be named chronic inflam- 
matory conditions of the brain and cord, and tumors of the brain. In 
forming a diagnosis we must carefully consider all the features which the 



HYSTERIA. 



973 



special affection from which the patient suffers presents, and how far and 
in what respects they differ from those of lesions of the same parts which 
are not of hysterical origin. We must also look carefully to the various 
complications which attend the main affection, or which supervene from 
time to time, or alternate with it ; for it rarely happens that a patient 
suffering from an hysterical joint or from hysterical hemiplegia or para- 
plegia, does not also at one time or another have an attack of aphonia, or 
retention of urine, or a bout of intermingled laughing and crying, or a 
distinct hysterical fit, or that the original affection does not undergo some 
striking change, or shift to some other part. Lastly, we shall often be 
importantly aided in coming to a decision by careful observation of the 
demeanor and conduct of the patient, and of her general tone of thought 
and feeling. [The inhalation of ether may sometimes be advantageously 
resorted to for the purposes of diagnosis. During the stage of excitement 
preceding insensibility, the hysterical patient will frequently move the 
limb or limbs which just before seemed completely paralyzed. The same 
remedy may also prove of service in cases of phantom tumors of the abdo- 
men, which, of course, entirely disappear under its influence. In some 
cases, indeed, etherization has appeared to be of service therapeutically, 
by convincing the patients that no real loss of power exists.] 

Hysteria is very common ; and varies from a slight affection of little 
importance to one of such gravity that it renders the patient a lifelong in- 
valid, and her existence a burden and a misery to herself and those about 
her. Fortunately the milder cases are by far the most common ; and in 
many of these complete recovery takes place, while in many recovery is 
so far complete that there only remains a liability to the outbreak of slight 
hysterical phenomena under special circumstances of ill-health or excite- 
ment. Not unfrequently, however, patients suffer from hysterical vomit- 
ing, alternating it may be or associated with other hysterical symptoms, 
for years ; or they remain hemiplegic or paraplegic and bed-ridden for one, 
two, ten, or twenty years ; or they suffer from urinary disorders, or apho- 
nia, or joint-affections for an equally indefinite period ; or they are the 
victims of constantly recurring violent fits. In some cases patients con- 
tinue thus for life. It may be said generally that the longer the phenom- 
ena have persisted, the less likely is ultimate recovery to take place ; but 
it must never be forgotten that (unless any organic complication has arisen) 
there is always a possibility that the patient will get well, and not only 
get well, but get well suddenly. The patient who has been confined to 
her bed paralytic for years will perhaps, under the influence of some sud- 
den impulse or mental or emotional excitement, recover the complete use 
of her limbs ; the patient who appeared doomed to lifelong voicelessness 
will suddenly speak aloud in her natural tone. 

Pathology — We do not pretend to give any account of the morbid 
anatomy of hysteria or of its pathology. On these heads little or nothing 
of any importance is known, and we do not care to speculate. It is, so 
far as we know, a purely functional disorder. 

Treatment — The treatment of aggravated hysteria is exceedingly dim- 
cult, and all the more difficult that the patient's condition excites in those 
about her that sympathy which she craves ; and that consequently that 
judicious firmness of management which the medical man should exercise 
is apt to be resented not only by herself but by her friends. Nothing, 
indeed, is more injurious to such patients than the pity and attention they 
receive ; they live for them, they lay their plans to attract them, and their 



974 



DISEASES OF THE NERVOUS SYSTEM. 



moral and bodily conditions deteriorate under their influence. On the 
other hand, the exercise of a judicious firmness is essential for their suc- 
cessful treatment ; and this it is impossible for the medical man to accom- i 
plish unless he acquires the confidence, if not of the patient, at all events 
of those under whose control she is. For this purpose it is not necessary 
to be harsh, indeed harshness is likely to defeat its object ; but the respect, 
and if possible the trust, of the patient should be acquired by the cultiva- ' 
tion of kindliness and friendliness of manner with firmness of purpose. 
There should be on the part of the doctor a judicious blending of the 
4 suaviter in modo' with the ' fortiter in re.' No doubt hysterical patients 
are extremely disposed to exaggerate their symptoms. No doubt they do 
occasionally wilfully and grossly deceive those about them ; but it must 
not be assumed that there is generally intentional exaggeration, still less 
that there is imposition. They do, as a rule, really surfer that of which 
they complain, and suffer more when their attention is directed to the ail- 
ing part. It is impossible in a brief space to lay down any rules with 
regard to the general treatment of these cases. No doubt it is important 
to improve the general health, to relieve dyspeptic symptoms, to cure 
anaemia, to regulate the catamenia, to see that the bowels act regularly, to 
insist on regular hours, good wholesome diet, and daily exercise, and it 
may be to order change of air and scene ; especially it is important to 
make the patient take an interest and pleasure in some useful occupation 
or some intellectual recreation or study. But it must never be forgotten 
that, to use Sir Thomas Watson's words, ' behind the moody, reserved, 
and tricky behavior there often lies some mental or emotional cause — some 
hope deferred or disappointed — which being ascertained, and capable of 
satisfaction and satisfied, the patient may be restored to her customary 
health.' 

Among the drugs which have been employed with more or less success, 
or want of success, may be especially mentioned iron, zinc, vegetable tonics, 
assafcetida and other fetid gum-resins, and stimulants. Alcohol in various 
forms is often recommended by the medical attendant or had recourse to 
by the patient ; but alcoholic beverages, chloral, opium, and other narcotic 
medicines, should be given or allowed with extreme caution, for the tem- 
porary relief which they give is very apt to lead to their habitual use and 
ultimate abuse. In the hysterical paroxysms very often nothing more is 
needed than to lay the patient down and unfasten her dress or anything 
tight about her neck ; the paroxysm may, however, frequently be cut short 
or prevented by the free use of cold water — by dashing it in quantity over 
the neck and face — or as Dr. Hare points out, by firmly closing the patient's 
nose and mouth for a time, or until her dyspnoea is such that she is com- 
pelled to draw a long breath. Less valuable than these measures, though 
not altogether to be despised, are the inhalation of sal-volatile or smelling 
salts, and the exhibition of ammonia, assafoetida, or ether. 

M. Charcot, besides pointing out the readiness with which hysterical 
paroxysms may be induced by pressure made in the region of one of the 
ovaries, shows that in the same cases powerful, regulated, and sustained 
pressure is generally efficacious in arresting the paroxysm, however violent 
it may be. 

The removal or relief of the various local phenomena of hysteria fre- 
quently demands special forms of treatment ; aphonia may generally be cured 
by faradism of the throat, effected either by placing one pole of the instru- 
ment within the throat and the other external to it, or by placing the poles 



CATALEPSY AND ECSTASY. 



975 



on either side externally. Paralytic affections are largely benefited by 
the same treatment, or by the frequent use of the cold douche. Dr. Rey- 
nolds especially recommends the application of narrow strips of blister 
around the affected limbs. Anaesthesia also is sometimes remediable by 
faradism. But for this, especially if there be at the same time coldness of 
surface and imperfect circulation, as also for the cure of hysterical contrac- 
tions, galvanism is probably preferable. 

It is mainly in cases of hysterical anaesthesia that Dr. Burq's 1 metallo- 
therapeutic treatment has come into vogue. This consists in the local 
application of some metal to which, by experiment, the patient is found to 
be sensitive. The metals employed are gold, silver, iron, copper, and zinc. 
To ascertain which of these is appropriate, disks of each must be applied in 
succession for two or three minutes each to the region about to be operated 
upon. This point having been determined, bands or groups of disks of the 
selected metal must be kept for a quarter of an hour or so in -close contact 
with the affected surface by a bandage or other means. It would appear 
that the result is that the affected part (whether it be the skin or organ of 
special sense) gradually recovers its sensibility, and that associated with 
this there is a return of warmth and circulation, and of muscular power. 
But it would also appear: that whatever improvement there is on the one 
side of the body, is at the expense of the opposite side, which becomes an- 
aesthetic in proportion as the other recovers ; and, moreover, that the re- 
covery is only temporary. 

The sudden cure of hysteria in any of its forms is almost always possible 
under the influence of powerful emotional excitement. Thus a sudden 
alarm that the house is on fire will sometimes cause a woman who has been 
paraplegic for years to rush from her bed with the full use of her limbs ; 
the unexpected infliction of sudden and severe pain generally suffices to 
make the dumb cry out at the top of her natural voice ; the promise that 
if a long-closed hand opens by a certain day it shall have a valuable trinket 
placed in it generally calls for fulfilment. 



XV. CATALEPSY, ECSTASY, AND OTHER CONDITIONS 
ALLIED TO HYSTERIA. 

A large number of curious nervous phenomena — motor, sensory, emo- 
tional, and intellectual — occur, which are difficult to describe save by the 
help of illustrative cases, difficult to classify, and difficult to attach to spe- 
cific lesions or specific conditions of the nervous system. In a large pro- 
portion of cases they originate in powerful mental excitement, and more 
especially in such as is connected with religious fervor; they sometimes 
also arise from imitation or moral contagion. Young persons, from the 
period of commencing puberty to the termination of adolescence, and more 
particularly females, or males of emotional temperament, chiefly suffer. 
The patients are often distinctly hysterical : and not unfrequently hysterical 
paroxysms and some of the various other phenomena which have been 
considered under the head of hysteria complicate some of the conditions we 

1 See report by MM. Charcot, Luys, and Dumontpallier, quoted in the British 
Medical Journal, May 19, 1877. 



976 



DISEASES OF THE NERVOUS SYSTEM. 



are now about to describe, or alternate with them. Indeed, if we look to 
the exciting causes, to the class of persons who are most commonly affected, 
to the character of the symptoms, and to their frequent association with 
hysterical phenomena, we can scarcely avoid regarding the affections under 
consideration as varieties of hysteria. We believe that they generally are 
so. In some cases, however, they seem to be related rather to chorea, epi- 
lepsy, or insanity. 

1. Rhythmical and other methodical movements These present innu- 
merable varieties of character. In some cases the patient, performs un- 
ceasing oscillatory, undulatory or rotatory movements of the head and 
neck, or of the entire trunk. In some she is seized with an uncontrollable 
impulse to run forwards or backwards. In some she is impelled from time 
to time to leap into the air. To the same class must be referred the violent 
rhythmical movements which attended the ' dancing mania' of the Middle 
Ages. 

2. Catalepsy By this term is meant an attack of loss of sensation and 

of consciousness, attended with remarkable stiffening of the muscles. The 
patient for the most part is attacked suddenly, after more or less mental or 
emotional disturbance ; she becomes pale and corpse-like, the respirations 
being slow and tranquil, the pulse soft. She cannot be roused, and is en- 
tirely insensible to pain. But the most striking phenomenon is the stiff- 
ness of the muscles, which is such that the limbs, head, and neck, or 
features, when forcibly put into any position, however constrained and 
unnatural it may be, or however difficult to be supported by the healthy 
muscles, retain that position for some length of time. But although the 
patient appears to be unconscious to external impressions, and to remember 
nothing of what happens during the attack, she will sometimes sing or talk 
whilst it is upon her, or indicate by her expressions the presence of pleas- 
ing or painful impressions. A cataleptic condition may also occur in 
patients who still retain full consciousness. Cataleptic attacks may last 
from a few minutes to several days ; there may be a single attack only ; or 
they may recur with more or less frequency. 

3. Ecstasy is a condition in which the patient is absorbed in some all- 
engrossing fancy or delusion. It is the condition to which weak-minded 
persons are wrought under the influence of revivalist preachers, and in 
which they are sometimes impelled to plead frantically for pardon for 
imaginary misdeeds, are sometimes in a delirium of complacency and joy 
at their supposed enrolment among the saved. It is the condition into 
which those persons fall who believe that they see visions of Christ, of the 
Virgin Mary, of saints, or of angels, or who hold familiar intercourse with 
them, or who receive divine messages. It is the condition into which the 
medium is not unfrequently brought under the mesmeric influence. It 
represents also the mental condition of the dancing maniacs of the Middle 
Ages. The nature of the fancies or delusions under which such patients 
labor may, therefore, present the widest range of variety, and their effects 
on the mind all degrees of intensity. Their influence over the actions of 
the patient, moreover, is very various. Thus, while one will gesticulate 
violently and roar or scream his prayers or denunciations ; another will 
dance or sing or utter pious ejaculations ; another will sit apart with an 
air of self-satisfaction or quiet happiness ; and yet another will be transfixed 
or stunned, as it were, with intense anxiety or horror. In some of these 
cases the patient remains motionless and apparently insensible to every 
external impression for days together. But generally they are not wholly 



TETANUS. 



977 



insensible ; and although the mind may not be capable of being diverted 
from its engrossing thoughts, the pupils contract and the eyelids close 
under the influence of a strong light ; sneezing and watering of the eyes 
may be induced by the application of ammonia or snuff; and the respira- 
tory muscles may be made to act powerfully under the shock of a jugful of 
cold water. 

4. Double-consciousness. — A curious condition, allied to the last, is ' 
sometimes witnessed, in which the patient appears to have, as it were, a 
double life — the one her normal state of existence, in which she is fairly 
sensible, and knows .and understands, and perhaps takes an interest in, 
everything that goes on about her ; the other a condition of ecstasy or 
somnambulism in which her mind is under the dominance of delusions, and 
in which the same lines of thought and feeling and the same delusions are 
continued through the successive ecstatic paroxysms ; and in neither of 
which has she any recollection or knowledge of what occurs in her alter- 
native condition. Occasionally these strange phenomena may be prolonged 
for years, the one state passing into the other almost suddenly several 
times a day. The waking condition, indeed, may form but a small por- 
tion of her existence, and may itself be attended with curious motor, sen- 
sory, or mental phenomena. 

Treatment In treating the various cases which have just been con- 
sidered it is important not to lose sight of the fact of their intimate relations 
with certain other nervous diseases, more especially epilepsy, hysteria, and 
insanity, of which indeed in the great majority of cases they may be 
regarded as mere varieties. Their treatment, therefore, resolves itself 
mainly into the treatment of these affections. Everything calculated to 
improve the general health of the body is indicated ; but if a cure is to be 
effected it is rather by judicious management than by medicines. 



XVI. TETANUS. (Trismus. Lockjaw.) 

Definition — Tetanus is an acute and generally fatal disorder, charac- 
terized by painful tonic spasms of the voluntary muscles, and usually trace- 
able to some local injury. 

Causation — Traumatic tetanus may originate in a simple bruise, a 
trivial graze of the skin, the wound inflicted by a mere splinter, or a clean 
cut. But it is far more commonly due to compound fractures or other 
injuries attended with laceration or crushing. It is generally believed 
that injuries of the extremities are much more liable to be followed by it 
than injuries of the head and neck or trunk ; but, as Mr. Poland justly 
remarks, the limbs are far more prone to accidents than other parts, and 
it is probably on this account alone that their wounds are credited with 
a disproportionate proclivity to tetanus. But climatic conditions also are 
largely concerned in the production of tetanus ; for the disease is much 
more common in hot than in cold or temperate climates ; and although it 
so frequently supervenes on wounds received in battle, it occurs much more 
frequently when the wounded are exposed to cold and wet than under op- 
posite circumstances. Indeed the idiopathic form of the disease, which is 
somewhat unfrequent, is usually referred, and probably with reason, to the 
influence of these latter agencies — agencies which also induce rheumatism, 
62 



978 



DISEASES OF THE NERVOUS SYSTEM. 



pneumonia, and other internal inflammations. Tetanus may occur in 
either sex, and at any age. In the West Indies it is very common in 
new-born children, in whom it is supposed by some to be due to the divi- 
sion of the umbilical cord ; and it occasionally happens in women after 
parturition. It has been attributed to intestinal irritation provoked by 
worms or other like causes. The supervention of traumatic tetanus ap- 
pears to be wholly uninfluenced by the character of the changes going on 
in the injured parts. 

Symptoms and progress — Tetanus comes on after injury at periods 
varying between a few hours and three or four weeks — most commonly, 
according to Sir T. TTatson, between the fourth and fourteenth day. TThen 
the disease is due to exposure T it always supervenes very quickly — occa- 
sionally in the course of a few hours. 

The first symptoms of which the patient complains are usually pain and 
stiffness of the muscles of the jaws and neck — symptoms which he probably 
refers to cold, and describes as sore throat and stiff neck. He has diffi- 
culty in opening his mouth, in masticating, and in moving his head, which 
is soon followed by dysphagia, and by spasmodic attacks of pain and ag- 
gravation of his difficulties, provoked especially by every attempt to use 
the affected muscles. By degrees the stiffness and tendency to painful 
spasm extend to the other voluntary muscles: to those of the back, which 
by their action on the trunk tend to curve the body backwards ; to the 
inspiratory muscles, especially the diaphragm, the implication of which 
involves more or less difficulty of respiration, and occasional attacks of more 
severe dyspnoea, attended with acute pain striking through from the ensi- 
form cartilage to the interscapular region ; to the muscles of the abdomen, 
which get rigid and knotted ; to those of the extremities, which become 
difficult of flexion, and from time to time powerfully and violently ex- 
tended ; and to those of expression, which by their tonic contraction im- 
press upon the patient's features a fixed painful look (the risus sardonicus ), 
which becomes intensified during each recurring spasm. The muscles of 
the tongue and eyeballs, and those which move the hands and feet, usually 
escape or are involved late and to a slight extent only. 

As the disease progresses all the implicated muscles become more or 
less permanently stiff, and the stiffness gradually increases. But from the 
beginning the patient is liable to paroxysmal attacks, during which all his 
symptoms are enormously aggravated, and which come on at irregular but 
diminishing intervals, sometimes every quarter of an hour, sometimes 
every ten or every five minutes, and last individually from a few seconds 
to several minutes. These occur for the most part spontaneously, but are 
readily induced by any muscular effort, by moving the patient, or even by 
the slamming of a door and other such-like trivial causes. 

In the fully-developed disease the patient, during the interparoxysmal 
periods, probably lies stiff in bed upon his back. The muscles of the 
trunk, limbs, and neck are hard and rigid ; the jaws cannot be opened at 
all. or admit of being separated only to the extent of a few lines ; the face 
wears a painful expression, the brows being knit and at the same time 
transversely wrinkled, the eyes somewhat closed, the angles of the mouth 
drawn outwards and upwards, the lips apart, and the grooves extending 
from the alae of the nose towards the angles of the mouth deepened ; the 
mouth and fauces are clogged with saliva, which he has difficulty in swal- 
lowing: the voice is feeble, possibly reduced to a whisper; and the respira- 
tions are rapid and shallow. Further, he probably complains of more or 



TETAN ITS. 



979 



less general pain or soreness, and especially of pain extending from the 
scrobiculus to the back. During the paroxysms his sufferings become ex- 
tremely aggravated, and frightful to witness. His arms and legs (espe- 
cially his legs) become more powerfully extended, and at the same time 
widely separated ; the extensor muscles of the spine arch the trunk and 
head and neck powerfully backwards, so that not unfrequently the patient 
rests only on his head and heels ; the respiratory muscles get more or less 
fixed, respiration difficult, and the face pale, livid, or ghastly ; the distor- 
tion of the features, moreover, is now extreme — the forehead corrugated 
by the combined action of the frontales and corrugators, the eyeballs fixed 
and staring, the eyelids rigid and partly closed, the nostrils dilated, and 
the angles of the mouth drawn outwards and upwards so as to impart that 
peculiar appearance of grinning which has been referred to. The lips 
moreover are retracted, exposing the clenched teeth ; between which 
bloody saliva occasionally flows in consequence of the accidental wound- 
ing of cheek or tongue by their sudden closure at the commencement of 
the paroxysm. The paroxysms are said frequently to come on with in- 
crease of the diaphragmatic pain ; and during their continuance cramp-like 
pains of the most agonizing character pervade the contracted muscles. 

Certain other phenomena to which it is desirable to draw attention pre- 
sent themselves in the course of tetanus. The pulse is, for the most part, 
rapid and feeble, and its rapidity and feebleness increase with the progress 
of the case, and are especially observable during the paroxysms. At such 
times also the skin, which is generally moist or perspiring, breaks out into 
profuse sweats. The urine is, for the most part, scanty, and the bowels 
are constipated; but the patient has entire control over bladder and rectum. 
According to Dr. Senator, there is no increase of excretion of the urinary 
solids. In the great majority of cases the patient retains his senses unim- 
paired throughout his illness, and is conscious up to the moment of death. 
He seldom sleeps, or he sleeps only by snatches. Sometimes the spasms 
cease entirely during sleep. The temperature in tetanus is generally some- 
what above the normal, and liable to irregular diurnal variations. It does 
not usually exceed 100° or 101°, but may rise from time to time, even in 
cases which ultimately do well, to 102°, 103°, or more. Nevertheless, 
when the temperature reaches or exceeds 103°, the symptom must be re- 
garded as of serious import. Occasionally, with the approach of death, the 
temperature rises rapidly, and it may then attain an elevation of 110° or 
even 112°. Sometimes in the course of tetanus the temperature becomes 
sub-normal. 

When the tetanic spasms affect only or principally the muscles of the 
jaw, the affection is often termed trismus or lockjaw. When, as usually 
happens, the body during the tetanic spasms is arched backwards, the con- 
dition is termed opisthotonos. In those rare cases in which, owing to the 
predominant action of other muscles, the body is curved forwards or to one 
side, the condition of emprosthotonos or pleurosthotonos, as the case may 
be, is present. 

The prognosis of tetanus is very gloomy ; almost all traumatic cases, 
and the great majoriy of idiopathic cases, die. According to Mr. Poland, 
taking all forms together, the mortality is at the rate of about 88 per cent 
The most rapid cases, according to the same writer, die in four or five 
hours. But death has been delayed until the thirty-ninth day. More than 
half the total number of fatal cases perish during the first five days. Death 
is usually caused either by asthenia or apncea, or by a combination of these 



980 



DISEASES OF THE NERVOUS SYSTEM. 



conditions. It not unfrequently occurs suddenly in one of the spasmodic 
attacks, and is then probably due immediately to spasm of the respiratory 
muscles, and possibly to those of the glottis. 

Tetanus may be simulated by hysteria, by inflammatory affections of the 
spinal cord, and especially by the effects of strychnia and other allied drugs. 
As regards the first two classes of disease, there can seldom be any real diffi- 
culty in distinguishing between them and tetanus, in consequence in the 
one case, of the supervention of paralysis or other signs of organic lesion 
of the cord, in the other case, of the association of various hysterical phe- 
nomena with the spasmodic muscular rigidity. Strychnia poisoning, on 
the other hand, may be readily confounded with tetanus. The chief dis- 
tinction between them lies (to quote Dr. Christison's words) in the fact 
that ' the fits of natural tetanus are almost always slow in being formed, 
while nux vomica brings on perfect fits in an hour or less.' Further, tet- 
anus rarely, if ever, 1 proves so quickly fatal as the rapid cases of poison- 
ing with nux vomica.' It need scarcely be added that the history and eti- 
ology of all cases in which tetanic spasms are present should be investigated 
with minute care. 

Morbid anatomy. — Various lesions have been discovered in the nervous 
system. In traumatic tetanus, the nerves proceeding from the injured 
region have been found swollen, hypersemic, and inflamed, either in part 
or in their whole length. In many cases, however, no such lesions have 
been perceived. It was formerly believed that the spinal cord was healthy ; 
but recent investigations, and more especially those of Drs. Lockhart 
Clarke and Dickinson, have demonstrated the presence, in some cases at 
least, of considerable dilatation of the small vessels (particularly the arte- 
ries and veins) with accumulation of blood within them and around them, 
together with more or less abundant translucent or finely granular exuda- 
tion, infiltrating the tissues, and tending to accumulate here and there, 
especially in the fissures, and occasionally on the surface of the cord. 
With these changes are associated sometimes more or less disintegration 
of the proper nervous elements, sometimes local effusions of blood. In 
trismus neonatorum, congestion of the spinal arachnoid is described, with 
effusion of serum and even extravasation of blood, into the subarachnoid 
tissue. It can scarcely be admitted, however, that these lesions are proved 
to be invariably present in tetanus. That the motor nuclei of the spinal 
cord and medulla oblongata are generally in a state of polarity or abnormal 
irritability, or that they are generally under the influence of some ab- 
normal condition which excites them to unwonted action, is clear enough. 
But whether this excited action is due to some peculiar change in the 
nerve-cells themselves, or to the influence exerted upon them by the con- 
gestion and effusion which surround them, or to the presence in the blood 
of some endopathic poison (as is suggested by Sir T. Watson and by Dr. 
Richardson) resembling strychnia in its effects, are points upon which as 
yet we can only speculate. It is uncertain, therefore, at present, whether 
the lesions which have been discovered in the spinal cord are in any degree 
the cause of the tetanic spasms, or whether they are merely secondary to 
them. Ruptures of muscular fibres are frequently seen after death from 
tetanus. They are common in the muscles of the back, but sometimes 
occur in the abdominal muscles and those of the extremities. 

Treatment No treatment, so far as we know, has any curative influ- 
ence over tetanus. A certain number of cases get well under the most 
unfavorable circumstances ; the great majority die in spite of the most 



CONGESTION AND ANAEMIA. 



981 



strenuous efforts to save them. Innumerable drugs have been employed, 
and, according to their several advocates, with more or less success. 
Among those which have acquired the greatest reputation are opium, mer- 
cury, wourara, Calabar bean, and chloroform. Many other medicines, 
for the most part sedatives, have also been recommended, especially, per- 
haps, aconite, belladonna, digitalis, tobacco, hydrocyanic acid, chloral, 
and turpentine. By some authorities, drastic purgatives have been lauded, 
by some, profuse stimulation by means of ether or alcohol. It is impor- 
tant to know that tetanic patients can take large doses of the most power- 
ful sedative medicines, and drink large quantities of alcoholic beverages 
without being brought under the influence of these agents. Warm baths, 
cold baths, ice to the spine, bleeding, division of the nerves leading to the 
injured spot, and even amputation of the limb or part on which the injury 
was inflicted, are measures which have each in turn been adopted and 
abandoned. 

As regards general rules of treatment we cannot do better than quote 
Sir T. Watson's words. He says : ' Since any, the smallest, movement 
or impression made upon the surface, or upon the senses, will bring on the 
severer degrees of spasm, it is of primary importance to protect the patient 
against those sources of trouble, so sure to aggravate his sufferings, and so 
likely to augment his danger. Hence, if blood-letting should be thought 
advisable, it should be done early, sufficiently, and once for all.' ' The 
same remark applies to the frequent use of purgatives. The bowels 
should be well cleared in the onset, and then let alone. The patient 
should lie in a darkened room, from which noise also should, as much as 
possible, be excluded. He should not be surrounded by a multitude of 
friends or attendants. He should be enjoined to speak, to move, to swal- 
low, as seldom as he can. In the severe traumatic cases, the nerve, in 
my judgment, should be promptly divided, and as high up in its course as 
may be practicable ; and in all cases, there being no special indications to 
the contrary, I should be more inclined to administer wine in large doses, 
and nutriment, than any particular drug. If the tendency to mortal 
asthenia can be staved off, the disturbance of the excito-motory apparatus 
may perchance subside or pass away.' The patient's sufferings may often 
be alleviated by the use of opium or chloroform inhalation. 



XVII. CONGESTION. ANEMIA. SUNSTROKE. 

A. Congestion and Ancemia. 

Symptoms — So many nervous phenomena are commonly referred to 
congestion or anaemia of the nervous centres, that we can scarcely presume 
to pass these conditions over in silence. And indeed, although we are 
disposed to assert that the great majority of cases in which symptoms are 
referred to them in practice are not true examples of anything of the kind, 
it must be freely admitted that congestion and anaemia of the brain and 
cord do really play an important part in the phenomena of disease in these 
organs. Whenever inflammation or other processes of proliferation are in 
progress congestion is necessarily present. We see the evidences of 
former congestion in the condition of the bloodvessels and of the parts 



982 



DISEASES OF THE NERVOUS SYSTEM. 



immediately bounding them in chorea, epilepsy, tetanus, and chronic in- 
sanity. In heart-disease, in chronic bronchitis, in cases in which tumors 
press upon the large veins at the root of the neck, during violent muscular 
efforts, in the attacks of hooping-cough, the brain also becomes more or 
less congested. Anaemia may be the consequence of abundant losses of 
blood ; it may be due also to obstruction of the common or internal caro- 
tid, or of one of the arteries distributed to the brain. But in the majority 
of the above cases, either the symptoms which the patient presents are not 
those commonly attributed to congestion or anaemia, or the symptoms ref- 
erable to these conditions are intermingled and confused with others 
dependent upon causes of a different kind. 

We shall not discuss the various symptoms, which on theoretical 
grounds might be attributed to cerebral and spinal congestion. It will be 
sufficient for our purpose to point out : that they must necessarily differ 
materially according as the congestion is acute or chronic, and according 
as it involves certain regions of these organs or pervades them generally ; 
and that abnormal congestion, if it be not excessive is likely to be 
attended with exaltation of function, if it be excessive is pretty certain to 
induce perversion or abeyance of function — vertigo, headache, delirium, 
convulsions, coma, paralysis, muscae and dimness of sight, noises in the 
ears, and dulness of hearing. The effects of temporary congestion are 
sometimes well seen in attacks of spasmodic cough, such as attend per- 
tussis, and the presence of thoracic aneurisms. The patient becomes more 
and more livid in the face, suffers from vertigo, headache, muscae, and 
noises in the ears, and presently becomes momentarily insensible, with 
probably some convulsive twitchings or spasms of the muscles of the eye- 
balls and of those of expression. 

The symptoms referable to anaemia, equally with those due to conges- 
tion, vary according as the anaemia is general or partial, acute or chronic, 
slight or extreme. Moreover, they are very much of the same kind as 
those which attend congestion. Thus, in cases in which the supply of 
blood to the brain is suddenly interrupted either by obstruction of one or 
more of the arteries supplying it, or by temporary arrest of the heart's 
action, or by copious loss of blood, insensibility and convulsions frequently 
ensue; and again, upon anaemia more slowly produced, it is not uncommon 
for delirium, resembling that of chronic alcoholism, or for acute mania, or 
for apoplectic symptoms to supervene. 

In many of the cases in which cerebral anaemia or congestion has been 
diagnosed during life, the condition of the brain appears post mortem to 
have been perfectly healthy ; and in some there has been found, from no 
obvious cause, accumulation of fluid in the ventricles or subarachnoid 
tissue. Hence it is possible that, at any rate in some cases, the symptoms 
referred to congestion or anaemia may really have been immediately due 
to the presence of serous effusion. It is possible, also, that in some cases 
they may have been due to the effects of undetected poisonous matters in 
the blood. Without venturing to decide upon what conditions of the 
brain each of them depends, we shall proceed very briefly to discuss two 
or three so-called functional disorders of this organ, which appear to 
belong to the group of affections we are now considering. 

1. Delirium tremens We have already (page 545 ) fully described 

this affection as it occurs in drunkards ; but it occurs also, though much 
less frequently, independently of alcoholism, and indeed in persons of 
abstemious habit, sometimes as a consequence of severe injury {delirium 



CONGESTION AND ANEMIA. 



983 



traumaticum), sometimes as a result of long-continued mental anxiety. 
The symptoms and progress of the disease are identical in all these cases, 
and need not be again detailed. 

2. Insanity Various forms of insanity, especially perhaps mania, 

melancholia, and dementia, are apt to come on during convalescence from 
acute febrile diseases, and after profuse hemorrhages. Their symptoms 
are in no way distinguishable from those of the same forms of insanity 
occurring under other conditions. Thej generally, however, end in more 
or less rapid recovery. 

3. Eclampsia — The convulsive attacks which may attend these condi- 
tions vary from mere momentary spasms of the muscles of the eyeballs or 
face, or some other limited part of the body, attended with momentary 
loss of consciousness, to epileptiform seizures of the most violent kind. 
And, indeed, there is nothing in the attacks themselves by which they are 
distinguishable from those of true epilepsy. The differential diagnosis 
must rest upon the associated phenomena of the case, and upon its history 
and progress. 

4. Apoplexy and paralysis. — The apoplectic attacks which appear to be 
due to merely functional disturbance of the brain have in many respects a 
close resemblance to those which are the result of hemorrhage. Their 
onset is sometimes sudden ; but it is more commonly gradual, the patient 
becoming drowsy, then semi-comatose, and finally, perhaps after remissions, 
passing into a state of complete stupor. When the apoplectic condition 
is fully established, the patient is absolutely insensible ; his pupils are 
probably dilated and inactive to light; he has lost the power of deglutition 
in a greater or less degree; his breathing is probably explosive or sterto- 
rous ; his arms and legs are motionless and flaccid ; he has no control over 
his emunctories; and his urine is retained. The phenomena may, how- 
ever, be as varied as those due to sanguineous effusion : and scarcely any 
of the symptoms which have been enumerated may not fail in certain 
cases, or be replaced by others. Especially it must be recollected : that 
partial or general convulsions may occur ; that the limbs, instead of being 
flaccid, may be rigid; and, indeed, that there may be distinct hemiplegia. 
The main distinctions between functional apoplexy and that from effusion 
of blood reside in their usually different modes of onset; in the paralysis, 
which in functional apoplexy is mostly general and attended with flaccidity ; 
in the pulse, which is usually accelerated in the affection now under con- 
sideration; and in the temperature, which here generally rises from the 
commencement of the attack, whereas in cerebral hemorrhage for some 
hours at least, it usually falls. 

These comatose attacks are not limited to elderly persons; they are 
somewhat common in lateral and disseminated sclerosis; and affections not 
clearly distinguishable from them are occasionally observed in young chil- 
dren, in whom they simulate the phenomena of meningitis. 

In connection with the apoplectic attacks, and occasionally indepen- 
dently of them, hemiplegic and other paralyses may occur. Affections of 
the sensory nerves also may supervene; and the patient may have dimness 
or loss of vision, or analogous conditions involving the sense of hearing. 

It need scarcely, perhaps, be said : that in each of the above cases the 
progress of the affection may closely simulate that of the malady which in 
its symptomatic phenomena it most closely resembles ; that in many in- 
stances complete recovery takes place within a shorter or longer time ; 
that in some instances relapses occur after such recovery ; that in some 



984 



DISEASES OF T EI E NERVOUS SYSTEM. 



permanent mental defect or paralysis follows ; and that not unfrequently 
death ensues. 

Treatment It is impossible to lay down any definite rules for the I 

treatment of these various functional disturbances. In the majority of 
cases the treatment should no doubt be the same as that for the affections i 
which they resemble. It is important however, to bear in mind that if 
they be traceable in any degree to loss of blood, to want of food, or to 
ansemia, however produced, it becomes essential to support the patient's 
strength by food and tonics. 

B. Sunstroke. (Coup de Soleil. Calenture. Insolatio.) 

Definition By the term 'sunstroke 7 is usually implied a more or less 

sudden attack of unconsciousness, occurring in persons exposed, under 
adverse conditions, to high temperature. It seems highly probable, how- 
ever, that more than one affection is included under this name. 

Causation — Sunstroke appears to result from prolonged exposure to 
intense heat, especially if the atmosphere be at the same time damp and 
impure, and the patient exhausted by long-continued over-exertion, and 
the wearing of clothes and accoutrements which impede the free action of 
his respiratory muscles. It often occurs, especially in tropical climates, 
from exposure to the direct rays of the sun ; but it is common also even 
in the night-time among persons who are subjected to intense heat in 
close, overcrowded, and ill-ventilated barracks, houses, or ships. Soldiers 
engaged in long and toilsome marches under the glare of a tropical sun 
are especially liable to suffer. 

Syynptoms and progress Sunstroke is sometimes sudden in its onset, 

but is more frequently preceded by premonitory symptoms. In the former 
case, the patient, who is probably engaged in some laborious occupation 
and exposed to the sun, suddenly falls down insensible and collapsed, with 
pale, cold, moist skin, gasping respiration, and extreme feebleness and 
rapidity of pulse. There is no doubt that, in these cases, equally with 
those next to be considered, the internal temperature at the time of the 
attack is above the normal. Death under these circumstances not unfre- 
quently takes place with great rapidity, or even quite suddenly. 

The premonitory or early symptoms of the other variety of the affection 
comprise, in a large proportion of cases,, great sense of weariness and 
prostration, vertigo, nausea, dryness and heat of skin, tendency to frequent 
micturition or even incontinence of urine, and restlessness or sleeplessness. 
The actual attack is sometimes ushered in with drowsiness, and the patient 
lays himself down to rest or sleep ; in other cases he is seized with momen- 
tary delirium or mania, more rarely with convulsions. Under any circum- 
stances the patient rapidly becomes comatose or apoplectic, and then pre- 
sents most of the ordinary phenomena of this condition. He lies perfectly 
insensible ; his pupils are contracted and unaffected by light, his conjunc- 
tivae injected ; he breathes rapidly, noisily, and sometimes stertorously ; 
his pulse is frequent, small, weak, and often irregular ; his face is pallid ; 
and his skin intensely hot. In some instances the patient remains per- 
fectly quiet during his comatose condition ; in others he is attacked with 
local or general convulsions of more or less severity. If death take place, 
it is rarely delayed beyond twenty-four or forty-eight hours. 

The mortality from sunstroke is very heavy, exceeding 40 per cent. 
Recovery is sometimes sudden and complete ; but it is more commonly 



SUNSTROKE. 985 

slow, and attended for some few days by feebleness of the heart's action 
I and oppressed breathing, and is then not unfrequently followed by conse- 
quences of more or less importance, such as headache, chorea-like affections 
of the muscles, epilepsy, and some degree of mental imbecility. These 
sequelae may be permanent. 

Morbid anatomy and pathology — In most cases of fatal sunstroke the 
blood is found to have remained uncoagulated ; the lungs are intensely 
j congested, and the right side of the heart is loaded with blood ; further, 
I there is generally more or less engorgement of the vessels of the brain, 
j The proximate cause of the disease is uncertain. By some it is considered 
that the symptoms are due to the circulation of poisonous matters in the 
blood. It is suggested by Dr. Geo. Johnson that the intense heat of the 
body is attended with dilatation of the pulmonary capillaries, engorgement 
of the lungs, and asphyxia, upon which the other phenomena of the disease 
presently supervene. The first symptoms, however, in many cases, are 
those of unconsciousness, and in all coma rapidly comes on with involve- 
ment of those organs, especially, which are in relation with the pneumo- 
gastric nerves. The symptoms differ indeed little, if at all, from those of 
the typical apoplectic state ; and it is difficult, therefore, to believe that 
they are not primarily cerebral. 

Treatment. — Indian practitioners are unanimous as to the danger of 
bleeding in these cases, and are equally unanimous with respect to the 
value of the cold douche, or of cold applied in other forms. Especially it 
seems advisable to apply cold to the head. Subsequently, if consciousness 
do not return, the head may be shaven, and counter-irritants used. The 
bowels should be made to act, but not violently purged. Generally, also, 
it is better to give nourishment and diffusible stimulants than to deplete. 

[Foreigners are the victims of sunstroke in such a large proportion of 
the cases occurring in the United States, that, in addition to the causes 
mentioned by the author, a certain amount of influence has been attributed 
by American physicians to want of acclimatization. Thus, out of sixteen 
cases treated under the writer's direction in the wards of the Pennsylvania 
Hospital, during the summer of 1868, the patient in one case only was an 
American. In estimating the importance of want of acclimatization as a 
predisposing cause of sunstroke, due weight must, however, be given to 
the fact that the greater part of our outdoor hard labor is done by Irish- 
men, who are thus peculiarly exposed to the action of the sun's rays. 

A temperature of 108° Fahr. has not unfrequently been noted in sun- 
stroke, and cases are on record in which it has exceeded 110°, but these 
are rare. The body also loses its heat very slowly after death, some 
observers even asserting that a slight increase occasionally takes place. 
In severe cases there is complete suppression of urine, and petechiae 
appear on the surface of the body, which is said by Dr. H. C. Wood to 
exhale a peculiar odor, by which the nature of the disease may oftentimes 
be recognized. The pupils, which are at first contracted, become, as 
death approaches, dilated, and sometimes unequally so. 

If death take place a few hours after the beginning of the attack, and 
an examination be made without much delay, the heart is observed to be 
rigidly contracted. Dr. H. C. Wood has shown that the same condition 
is produced in animals if their temperature be raised artificially a few 
degrees above the normal point. This contraction of the heart he believes 
to be due to the coagulation of the cardiac myosin, a result which is favored 
by a high degree of heat. The heart, however, will be found flaccid if the 



986 



DISEASES OF THE NERVOUS SYSTEM. 



attack has been a prolonged one, or if the autopsy has been deferred until 
putrefactive changes have set in. 

The presence of hyperpyrexia, together with many of the lesions it 
produces, has led many physicians to hold the opinion that sunstroke 
is a form of fever, and it has consequently been proposed to call it 4 Heat,' 
or ' Thermic Fever.' Dr. Wood, who is an advocate for this view, teaches 
that heat produces the fever by paralyzing a hypothetical centre, situated 
either in the medul]a or higher up, whose province it is to influence, 
through the vaso-motor or other nerves, the heat production in the body. 
But it would seem that at least equally strong arguments could be ad- 
vanced for considering the condition following certain injuries of the spinal 
cord a fever, since these not unfrequently give rise to a marked increase 
of temperature. 

The treatment should consist in the employment of all remedies which 
are capable of causing a rapid removal of the excessive heat, and these 
will include not only cold douches and affusions, but baths of ice-water. 
If these are not obtainable, the patient's body should be thoroughly rubbed 
with ice, while pieces of ice are placed about his head. When convulsions 
occur, hypodermic injections of morphia should be administered. These 
will often yield very good results, and may also be used when the patient 
is restless or excitable. Out of the sixteen cases above referred to, all of 
which were treated by rubbing with ice, but one case proved fatal, which 
is a much better result than has been obtained from any other method of 
treatment. In those cases of exhaustion from heat in which the thermo- 
meter indicates a low temperature, stimulants and the hot bath should be 
employed.] 



XVIII. MEGRIM. (Migraine. Hemicrania. Sick-headache.) 

Definition — A form of headache, for the most part circumscribed, 
coming on in paroxysms, and frequently attended with sickness, affection 
of sight, and other nervous phenomena. 

Causation — Megrim appears in a large number of cases to be an 
hereditary disease; and, when of distinctly hereditary origin, not unfre- 
quently commences during the period of the second dentition, from which 
age up to thirty it usually first declares itself. It rarely commences after 
thirty, and generally, even in those who are liable to it, subsides with 
advance of years. Patients do not often suffer from it after fifty. Females 
are somewhat more prone to it than males. The determining causes of 
the attack are very various. Amongst the most common of them are, 
disturbance of the digestive organs, such as may arise from over-feeding 
or prolonged abstinence, uterine disorders and the catamenial period, 
sustained mental labor or excitement, emotional disturbance, bodily fatigue 
or want of exercise, insufficient or over-abundant sleep, overcrowded rooms, 
foul air, and meteorological conditions ; and, besides these, impressions 
upon the senses, such as are produced by glaring lights, rapid successions 
of objects presented to the eye, loud or discordant noises, strong odors, 
and offensive smells. Megrim, or a condition undistinguishable from it, 
may arise also in the course of an ordinary catarrh, or be induced by ex- 
posure of the head to a current of cold air, or by malaria. 



MEGRIM. 



987 



Symptoms and progress — In the simplest and most common form of 
megrim, the patient is attacked, more or less suddenly, with dull pain usu- 
ally referred to a limited surface immediately over the eye or in the temple. 
This gradually extends in area, and becomes more intense, but usually still 
remains limited to one side of the head. It varies in intensity from time 
to time, is for the most part aching, but is not unfrequently attended with 
sudden shootings, and generally with throbbing, which is always greatly 
increased by bodily or mental exertion. It often involves the eye; and 
this, together with the scalp, is apt to become more or less hyperaesthetic 
or tender. The head is generally hot, and the arteries of the affected 
region manifestly dilated. In many cases the pain affects both sides of 
the head, although even then it is usually more intense on one side than 
the other; occasionally it attacks the occipital instead of the frontal region ; 
and sometimes it becomes generally diffused. From the commencement 
the patient is dull and indisposed for or incapable of mental or bodily 
exertion, and with the continuance of the headache these conditions in- 
crease upon him, and he becomes pale and chilly, and looks heavy, de- 
jected, and miserable. Not unfrequently he has a vague dread, or sense 
of impending evil ; and especially he is apt to experience a general feeling 
of profound illness, attended with tremulousness, shivering, and weakness 
of the limbs. The pulse for the most part is small and weak, and often 
slower than natural. After a variable time a sense of nausea supervenes, 
and in a large proportion of cases culminates in more or less severe vomiting, 
during the attacks of which the headache generally attains its greatest 
degree of intensity. After the vomiting has ceased the patient probably 
goes to sleep, and at the end of some hours awakes in pretty nearly his 
usual condition of health. 

In a large number of cases other symptoms are associated with those 
just considered, and then for the most part precede them. Among the 
most interesting of them are disorders of vision. When these occur, they 
are probably always the earliest in the sequence of events ; and they gene- 
rally vanish with the supervention of headache. They vary in character: 
in some cases certain portions of the retinae become simply insensible, and 
if the central spots of the eyes be involved, the patient, who probably feels 
well in all other respects, notices that he cannot see the nib of the pen with 
which he is writing, or the letters which he is forming, or that, while dis- 
tinguishing all other parts of the body, he cannot see the face of the person 
at whom he is looking ; in some cases he observes a tremulous vibratile, 
or rotatory movement in some part or other of the field of vision; some- 
times these tremulous areas or spectra become variously colored ; double 
vision sometimes occurs. The patches of retinal anaesthesia, or derange- 
ment, appear always to occupy identical parts in both eyes, and are apt to 
vary in shape from time to time. The coloration of the spectra, when it 
occurs, is always secondary. 

Other senses are apt to suffer, but on the whole much less frequently 
than sight; and the phenomena referable to them when associated with 
ocular derangements, always come on later. Occasionally the patient 
experiences deafness or noises in the ears or loss or perversion of taste or 
smell; but more frequently, perhaps, he is attacked with numbness, pass- 
ing on may be to complete anaesthesia, of the upper extremity, of the half 
of the head and neck and face, arid even of the parts within the mouth, 
all on the same side as the cephalic pain. This loss of sensation is some- 
times associated with more or less complete muscular paralysis. Further, 



988 



DISEASES OF THE NERVOUS SYSTEM. 



the cephalalgia is not unfrequently associated with the presence of distinct 
neuralgic pains, not only at the back of the head, but in the back and 
side of the neck, and even in the shoulder and down the arm. 

It has already been observed that the patient becomes more or less dull 
and apathetic and incapable of intellectual exertion : but psychological phe- 
nomena of a more remarkable kind are apt to ensue. Sometimes there is 
marked mental confusion or incoherence of thought, sometimes indeed 
typical aphasia. Drowsiness is very common : often forming one of the 
earliest indications of the attack ; sometimes coming on during its progress, 
and culminating in a more or less prolonged semi-comatose condition; but 
much more frequently constituting the termination of the attack. 

Megrim begins in many different ways. In some cases it supervenes 
immediately upon exposure to its exciting cause, as when the characteristic 
headache attacks the sufferer while he is at the theatre, or at a picture 
gallery, or during exposure to discordant noises or offensive smells, or 
while he is engaged in some laborious mental occupation. Not unfre- 
quently it comes on during the night, the patient waking from time to time 
with the consciousness of heaviness in the head, and getting up with the 
attack well developed ; or it manifests itself when he wakes in the morn- 
ing, or immediately after rising. In other instances it comes on at various 
times of the day, without obvious immediate cause. In a large propor- 
tion of cases the headache is the first symptom. In many, however, this 
is preceded by some of the prodromal phenomena above considered — the 
patient experiences a sense of general illness or of depression or dread ; 
or he has numbness, or confusion of thought, or extreme drowsiness, or 
other of the psychical phenomena which have been enumerated ; or he has 
some affection of vision. It is curious, as we have already shown, that 
when these several phenomena, or any of them, manifest themselves, they 
almost invariably precede the headache. It must be added that the attack 
may be limited to any one of these symptoms. 

The duration of megrim varies for the most part between twelve and 
twenty-four hours ; it may, however, last an hour or two only ; and it may 
be prolonged, but generally by successive relapses, for several days. The 
subsidence of the attack is generally gradual ; in a large number of cases 
it is preceded by vomiting ; and in the great majority (whether vomiting 
have taken place or not) the patient after a while sinks into a profound 
sleep, from which he wakes refreshed, and probably well. The patient 
during convalescence often perspires profusely, and excretes a large quan- 
tity of urine. 

Megrim is essentially a periodical disease, and in those who are liable to 
it not unfrequently comes on with more or less regularity once a week, 
once a fortnight, or once a month. It not uncommonly, however, occurs 
less regularly, and more distinctly in response to certain definite causes to 
which the patient exposes himself. Moreover, it often ceases for a time 
under various circumstances, such as pregnancy, suckling, and change of 
air or occupation, and occasionally is developed only at long intervals in 
connection with special causes of ill-health. 

Pathology Megrim has often been regarded as essentially a symptom 

of disorder of the liver or stomach : and no doubt affections of these 
viscera, but more particularly of the stomach, must be regarded as some 
of its exciting causes. But, on the other hand, the attacks so frequently 
arise independently of any morbid condition of the digestive organs that 
we are compelled to look elsewhere for its essential seat. It has latterly 



MENIERE'S DISEASE. 



989 



been referred to disorder of the cerebral circulation due to the influence of 
the vaso-motor nerves on the vessels of the part supposed to be implicated. 
Dr. Latham believes that its primary cause is some affection of the vaso- 
motor nerves, in virtue of which the vessels become contracted and the 
tissues ansemic ; and that it is to anaemia thus produced of the central 
nervous organs that the defects of vision and other early phenomena are 
due. And he refers the headache, which is generally if not always attended 
with manifest dilatation and throbbing of the temporal arteries, to secon- 
dary hyperemia. Dr. Liveing, however, points out that even if, as seems 
not improbable, some of the phenomena are referable to anemia and hyper- 
emia, there must still be some antecedent cause to which the vaso-motor 
affection itself is due. And he contends that the phenomena of the dis- 
ease depend on the irregular accumulation and discharge of nerve-force ; 
that the immediate antecedent of the attack is a condition of unstable 
equilibrium, and gradually accumulating tension in the parts of the nervous 
system more particularly concerned ; and that the paroxysm itself may be 
likened to a storm. He regards the optic thalami and all those parts which 
lie between these bodies and the roots of the vagi as the seat of disease. 
Megrim would seem, according to this hypothesis, to have a close patho- 
logical relation with epilepsy. The diseases do not, however, pass into one 
another. 

Treatment In the first place it is important for the patient to avoid 

those conditions to which his attacks seem to be traceable ; it is especially 
important also for him to live wholesomely, to avoid gastro-intestinal dis- 
turbance, to take plenty of exercise, to inhale the fresh healthy air of the 
country, and to refrain from too prolonged or intense mental labor, worry, 
or excitement. Various remedies are employed, reputedly with more or 
less success, to prevent the occurrence of attacks of megrim ; among others, 
iron, zinc, arsenic, iodide, bromide and chloride of potassium, quinine, 
strychnia, belladonna, hyoscyamus, and valerian. During the paroxysms, 
nothing is so efficacious as complete rest in the recumbent posture, in a 
darkened and perfectly quiet room. Relief may often be afforded, how- 
ever, by the administration of strong tea or coffee, or of caffeine, theine, 
guarana or croton chloral. Occasionally a full dose of brandy, ammonia, 
or one of the fixed alkalies benefits the patient. Evaporating lotions, 
belladonna, or aconite locally applied are often of great service. The aco- 
nitia ointment is especially valuable in many cases in warding off or sub- 
duing the headache. But local measures, although they relieve pain, do 
not prevent or curtail the other phenomena of the attack. The headache 
may sometimes also be soothed by pressure upon the carotid or temporal 
artery of the affected side. 



XIX. MENIERE'S DISEASE. {Aural Vertigo.) 

Definition — A disease characterized by sudden attacks of vertigo in 
connection with lesions of the semicircular canals. 

Causation and pathology — Experiments performed on the lower ani- 
mals, in the first instance by Flourens and subsequently by other observers, 
have distinctly proved that injury of the semicircular canals is followed by 
vertiginous movements, which have some definite relation to the particular 



990 



DISEASES OF THE NERVOUS SYSTEM. 



canal operated upon. To this subject attention has already been directed. 
It was M. Meniere, however, who first, in the year 1861, recognized and 
described the phenomena due to disease of these organs in the human 
being. 

Many cases have now been recorded in which the group of symptoms 
presently to be considered has been found associated with more or less im- 
pairment of hearing ; and in several of them post-mortem examination 
has revealed the presence of inflammatory exudation strictly limited to 
the semicircular canals. There is good reason, however, to believe that 
similar effects may be produced indirectly in diseases of the middle ear or 
other neighboring parts, by the pressure which is apt to be exerted upon 
the contents of the labyrinth, and through them on the semicircular canals. 
Hence they may result from catarrh, and complicate ordinary forms of 
otitis. 

Symptoms and progress — The specific phenomena of Meniere's disease 
are sometimes preceded by deafness, earache, and other indications of aural 
mischief. But in a considerable number of cases they manifest themselves 
without any such prodromata. The patient is suddenly attacked with 
noises in his ears, or in one of his ears, and a feeling of vertigo — symptoms 
which are attended with faintness, pallor, perspiration, nausea, and prob- 
ably actual vomiting. The attack is of short duration, sometimes lasting 
two or three seconds only ; and usually the recovery of the patient from it 
is for a time complete. 

The noise, as above stated, is sometimes referred to one ear only, some- 
times to both ; but in the latter case it is generally more pronounced on 
one side than the other. It differs in intensity in different cases, and is 
variously described as buzzing, humming, whistling, or singing, and is 
likened sometimes to the puffing of a steam-engine, sometimes to a sudden 
explosion. The sense of vertigo varies in severity and duration ; in some 
cases there is a mere momentary feeling of giddiness, or a feebler but more 
prolonged sensation of swimming in the head which resembles that attend- 
ing sea-sickness ; in some cases the patient feels as if he were suddenly 
thrown forwards, backwards, or laterally, or rotated, and he staggers or 
falls in the direction which corresponds with his sensation, clutching at 
neighboring objects for support, or actually falling to the ground. The 
attack is always attended with a sense of anxiety or alarm and more or 
less faintness. The latter condition may reveal itself by a momentary 
pallor, precordial anxiety, and failure of cardiac action, or by all the ordi- 
nary signs of well-marked syncope, followed by sweating, and extreme 
rapidity and feebleness of pulse. A feeling of nausea is probably always 
present in a greater or less degree ; but not unfrequently vomiting ensues, 
and with its occurrence the attack usually comes to a close. 

The vertiginous seizure, however severe it may be, is never attended 
with actual loss of consciousness ; and there is never any convulsive move- 
ment, paralysis, implication of speech, squinting, sensation which can be 
likened to the epileptic aura, or indeed any phenomena, beyond those above 
described as constituting the attack, which in any sense point to the pre- 
sence of cerebral mischief. Headache even is unfrequent. 

The fits come on in the first instance at irregular and probably distant 
intervals; but they tend gradually to increase in frequency and to approach 
one another; and sooner or later, probably, a time arrives when the patient, 
though still suffering from more or less frequent paroxysms, is never free 
from some degree of vertigo. 



PARALYSIS OF THE OCULO-MOTOR NERVES. 



991 



The noises in the ear which attend the early attacks of vertigo are not 
necessarily associated with deafness ; indeed, sometimes hearing is preter- 
naturally acute, and discordant or loud noises are peculiarly painful to the 
patient. Occasionally the range of audition becomes contracted. At this 
time also it not unfrequently happens that no affection of hearing is ob- 
servable between the attacks. But by degrees the noises in the ear become 
constant, though still undergoing exacerbation when the paroxysms occur; 
and the sense of hearing grows gradually more obtuse, until ultimately 
absolute deafness of the affected ear probably ensues. It is a curious fact 
that, with the supervention of absolute deafness, not only do the parox- 
ysmal attacks generally cease, but with them the continuous sense of gid- 
diness which had probably also been present. 

Slight and momentary attacks of giddiness, essentially resembling those 
above described, are by no means uncommon in connection with various 
temporary or permanent affections of the middle ear, and are then fre- 
quently induced immediately by loud or discordant noises, or by other 
powerful impressions on the senses. In such cases, however, complete 
recovery may be anticipated, and the disease seldom takes the course which 
has been above sketched. 

Treatment It is impossible to lay down rules for the treatment of 

Meniere's disease. It is important, however, to bear in mind that the 
vertiginous attacks are relieved though not prevented by lying down, and 
in many cases by carefully protecting the patient from all noises and other 
such influences. Further, it is obvious that when the symptoms depend 
on the presence of disease of the accessible parts of the ear, treatment 
directed to these parts should be employed. 



XX. LOCAL PARALYSES. 

A. Paralysis of the Third, Fourth, and Sixth, or Oculo-motor Nerves. 

Causation. — Paralysis of these nerves is probably always the conse- 
quence of some lesion involving them either at their origin or in some part 
of their course. Among such lesions may be named syphilitic disease of 
the base of the skull or contiguous parts of the brain ; tubercle, carcinoma, 
or other forms of morbid growth, or inflammatory exudation, occupying 
the same situations; tumors or accumulations of fluid or blood situated in 
the superincumbent brain-substance, and causing pressure: and aneurisms 
or tumors in the course of the cavernous sinus. Oculo-motor palsy is 
common in locomotor ataxy. 

Symptoms and diagnosis — In order to determine the situation of lesions 
causing the various oculo-motor paralyses, and to distinguish the paralyses 
due to individual nerves, it is essential, on the one hand, to have a clear 
view of the relations of the oculo-motor nerves at their origin and in the 
various parts of their course ; and, on the other hand, to have an exact 
knowledge of the normal actions of the muscles which they supply. 

In reference to the anatomical point, it must be borne in mind : that 
the nuclei of the third and fourth nerves are in close relation with one 
another in the floor of the iter, and that the sixth arises, in common with 
the facial, in the floor of the fourth ventricle ; that the muscles supplied 



992 



DISEASES OF THE NERVOUS SYSTEM. 



by these nerves are seven in number, namely, the levator palpebral supe- 
rioris, the four recti, and the two obliqui ; and that of these the external 
rectus is supplied by the sixth alone, the superior oblique by the fourth 
alone, and all the other muscles by branches of the third. 

The muscles of the eyeball are six in number, and arranged in antago- 
nistic pairs, which severally rotate the eyeball in opposite directions upon 
an axis perpendicular to the plane in which they respectively act, and 
passing as nearly as possible through the central point of the globe of the 
eye. These several pairs are the internal and external recti, the superior 
and inferior recti, and the superior and inferior obliqui. And the axes 
of rotation of the eyeball which correspond to them (see fig. 12) are (sup- 
posing the left eye to be under consideration, and its line of vision to be 



Fi<r. 12. 









\ I 






'\ 70° 













Horizontal section of left eye seen from above. 

_ a a, Antero-posterior diameter of eye ; b b, transverse diameter of eye ; r r, fixed axis of rota" 
tion tor movements effected by superior and inferior recti; o o, fixed "axis of rotation for move- 
ments effected by obliqui. 



fixed directly forwards) : — for the external and internal recti, a vertical 
straight line passing through the centre of the eye ; for the superior and 
inferior recti, a horizontal straight line (r r) passing obliquely through the 
centre so that its nasal extremity is a little in advance of its temporal 
extremity, and forming an angle of about 70° with the line of vision ; for 
the obliqui, another horizontal straight line (o o) passing also obliquely 
through the centre, but in such a direction that it makes an angle of 35° 
only with the line of vision — its temporal extremity being just a little be- 
yond the outer margin of the cornea, and its nasal extremity towards the 
back of the eye, a little internal to the optic disk. 

It may be assumed as sufficiently accurate for all practical purposes : 
that the ball of the eye is globular ; that it is lodged in a socket bounded 
by fat, connective tissue, and membrane, in which it moves as the head 
of the femur moves in the cotyloid cavity ; that its centre of rotation is 
the actual centre of the eye ; and further, as Helmholtz shows, that in 
consequence of the fixed origins of the oculo-motor muscles, and their 
broad insertions, the three axes of rotation which have been indicated 
remain unalterable in their relation to the fixed points of the orbit, no 
matter how much the line of vision — the line in which the eye is looking 
— become altered. 

It follows (see fig. 13) from the above considerations: — first, that the 
internal and external recti always cause the cornea to revolve around a 



PARALYSIS OF THE OCULO-MOTOR NERVES. 993 

vertical axis, to move therefore either in a horizontal equatorial line, or in 
proportion as it is elevated or depressed below this line in the arcs of 
smaller and smaller parallel circles ; second, that the superior and inferior 
recti always cause the cornea to revolve around the oblique horizontal 



Fig. 13. 
L 




L 

Left eyeball with iris and pupil seen from the front. 

o, Anterior pole of axis of rotation for obliqui ; r, anterior pole of axis of rotation for superior 
and inferior recti ; bl, upper and lower poles of axis of rotation for internal and external recti. 

Theconcentric circles around o and r respectively indicate the direction and amount of move- 
ment of the different parts of the ^lobe due to the action of the obliqui and superior and inferior 
recti respectively; the horizontal lines have a similar relation to the movements about the axis b b. 

axis, whose position has already been defined, and hence in the arcs of 
circles which are parallel to a vertical equatorial section of the eyeball, 
made through or near the outer margin of the cornea (as the eye looks 
directly forwards) in front, and the inner margin of the optic disk behind, 
so that the circles to which these arcs belong become smaller and smaller 
from the outer to the inner canthus of the eye, and the influence of the 
recti in causing vertical movements of the cornea correspondingly dimin- 
ished ; third, that the obliqui always causes the cornea to revolve around 
the oblique horizontal axis which has been referred to these muscles, and 
hence in the arcs of circles which are parallel to a vertical equatorial 
section of the eyeball, made through or near the inner canthus ; the cir- 
cles, to which these arcs correspond, commencing in a point a little outside 
the outer margin of the cornea, become larger and larger towards the inner 
angle of the eye, so that the influence of the oblique muscles upon the 
cornea varies from the production of simple rotation, when the eye looks 
outwards, to equatorial amplitude of movement when the eye is directed 
towards the inner canthus. It follows, further, that while all horizontal 
consensual movements of the two eyes can be effected by means of the 
inner and outer recti only, all vertical consensual movements require the 
co-operation of the superior and inferior recti and obliqui. 

Paralytic affections of the muscles of the eyeball are attended for the 
most part with squinting and double vision — the direction and character 
of the squint being different for each muscle affected, and the position of 
the object, as seen by the squinting eye in relation to that seen by the 
normal eye, being either internal or external to it, above or below it, or 
tilted. The existence of double vision is sometimes not recognized by the 
patient when the axis of his eyes diverge very widely ; moreover, the 
double image tends to merge into one, and the squint to become unappa- 
rent, in proportion as the patient turns his sound eye in the direction 
towards w r hich the squinting eye inclines. 
G3 



994 



DISEASES OF THE NERVOUS SYSTEM. 



In testing the eyes with the object of discovering the existence of double 
vision and the peculiarities it may present, it is generally convenient to 
place a colored glass before one of them, in order that the patient may be 
able to distinguish and indicate by their respective colors the two images 
which he sees. 

Assuming the left eye to be affected, the following would seem to be the 
consequences of paralysis of its several muscles taken singly : — 

Internal rectus Outward squint. Displacement of false image in hori- 
zontal line, to patient's right. Image not tilted. (See fig. 14.) 

External rectus — Inward squint. Displacement of false image in hori- 
zontal line, to patient's left. Image not tilted. (See fig. 15.) 

Superior rectus — Downward squint. Displacement of lalse image 
upwards. Elevation of pupil above horizontal line effected solely by 
inferior oblique ; its upward movement, therefore, is in a curve directed 
upwards and to the left ; it is ample when the pupil is directed inwards, 
but when the pupil is directed outwards, consists in a mere rotation of it 
upon its axis. Under these circumstances, the false image is tilted to the 
patient's right. (See fig. 16.) 

Inferior oblique Downward squint. Displacement of false image 

upwards. Elevation of pupil above horizontal line effected by superior 
rectus ; its upward movement, therefore, is in a curve, directed upwards 
and to the right; it is most ample when the pupil is directed outwards. 
The false image, when the pupil is above the horizontal line, is tilted to 
the patient's left. (See fig. 17.) 

Inferior rectus Upward squint. Displacement of false image down- 
wards. Depression of pupil below horizontal line, accomplished by superior 
oblique. Its downward movement consequently is in a curved line, directed 



Fig. 14. 



Fig. 15. 



Fig. 16. 






Fig. 17. 




Fig. 18. 



Fig. 19. 




In the above diagrams the thick cross represents the true image, the thin 



the false image. 



downwards and to the left, being a mere revolution upon its axis when the 
eye is directed outwards, but becoming more and more ample as the eye 
tarns to the right. False image, when patient is looking downwards, 
tilted to his left. (See fig. 18.) 



PARALYSIS OF THE FIFTH NERVE. 



995 



Superior oblique. — Upward squint. Displacement of false image down- 
wards. Depression of pupil below horizontal line, effected by inferior 
rectus. Its downward movement takes place, therefore, in a curved line 
directed downwards and to the right, the movement being most ample 
when the eye is directed outwards, least ample when it looks inwards. 
When the pupil is below the horizontal line, the false image is tilted to 
the patient's right. (See fig. 19.) 

It does not generally happen, however, that one muscle only is affected, 
unless it be the external rectus, or that when two or three muscles are in- 
volved they are completely paralyzed ; and consequently it is often difficult 
to determine the respective shares which different muscles take in oculo- 
motor paralysis. Paralysis of the third pair very frequently cause ptosis, 
together with dilatation and immobility of the pupil. When the oculo- 
motor branches of the third nerve are all implicated, the eye assumes an 
external squint, and the pupil is commonly directed a little downwards. 
Paralysis of the sixth pair is not unfrequently bilateral, probably because, 
from the long course which these nerves take along the floor of the skull, 
and from their position between this and the pons, they are peculiarly ex- 
posed to pressure and involvement in intra-cranial inflammatory and other 
morbid processes. 

Treatment The treatment of paralysis of the muscles of the eye must 

be determined by the opinion we form of the nature of the lesion causing 
it. Iodide of potassium and mercury are indicated in syphilitic cases. 
Electricity, applied to the muscles, is sometimes serviceable. However it 
may be explained, patients often recover from these paralyses. 

B. Paralysis of the Fifth Nerve. 

Causation. — This, like paralysis of the oculo-motor nerves, may be 
caused by various lesions implicating the nucleus of the nerve or the 
nerve itself in some part of its course. It is most commonly of syphilitic 
origin. 

Symptoms and diagnosis — The nerve may be implicated wholly or in 
part, and in the latter case the affection may be limited either to its oph- 
thalmic, to its superior maxillary, or to its inferior maxillary division. 
When the affection is total, there is complete anaesthesia of all those parts 
to which the nerve is distributed, and at the same time complete paralysis 
of all the muscles of mastication which it supplies. The loss of sensation 
involves the anterior half of one side of the head and face as far back as 
the ear, inclusive of the conjunctiva, cornea, and eyelids, the mucous 
membrane of the nose, lips, cheek, gums, and palate, the tongue (except- 
ing in the neighborhood of the circumvallate papillae), and the external 
auditory meatus. Consequently, the conjunctiva is insensible to all ex- 
ternal impressions, and liable, therefore, to get irritated and inflamed; its 
irritation, moreover, is unattended with reflex phenomena ; the sense of 
smell is impaired, mainly from tendency of the Schneiderian membrane 
to inflame, but partly from loss of power to appreciate impressions made 
by pungent vapors or gases ; the sense of taste is annulled in the anterior 
two-thirds of the tongue; and, partly from the loss of ordinary sensation 
in one-half of the oral mucous membrane, mastication becomes difficult on 
the corresponding side, and food tends to collect unknown to the patient 
between the cheek and gums, or between these and the tongue. 

The chief muscles supplied by the motor portion of the nerve are the 



996 



DISEASES OF THE NERVOUS SYSTEM. 



temporal, masseter, and pterygoids. The temporal closes the jaw, and, at 
the same time, draws it more or less backwards ; the masseter and internal 
pterygoid also close the jaw, but tend to draw it forwards; the external 
pterygoid co-operates to some extent with the last, but is especially the 
muscle by which the jaw is thrown forwards. Collectively they close the 
jaw, and effect the various horizontal movements of trituration. If they 
be paralyzed, neither the temporal nor the masseter can be felt to harden 
in contraction as do those of the healthy side, when the teeth are being 
firmly closed ; when the lower jaw is retracted it is drawn back obliquely 
with an inclination to the healthy side; when it is protruded, it is pro- 
truded obliquely with an inclination to the paralyzed side. The last 
deformity becomes especially remarkable when the patient opens his 
mouth wide, for not only is the jaw then displaced in a very high degree 
towards the paralyzed side, but the oral orifice becomes lopsided, and the 
muscles connected with the affected side of the lower lip appear to act 
more powerfully than their fellows. The difficulty of masticating on the 
diseased side is necessarily largely dependent on the weakness of its 
muscles. 

We have referred to the tendency which the affected side has to get 
congested and inflamed. These conditions may supervene in the mucous 
membrane of the mouth or nose, or in the conjunctiva. It is most com- 
monly observed, however, in the cornea, which is apt within a few days of 
the occurrence of paralysis to become opaque, to ulcerate, and to slough. 
These nutritive lesions doubtless obey the law which has previously been 
considered ; that is, they occur not so much when the continuity of the 
nerve is absolutely destroyed as when the implication of the nerve or of 
its nucleus is incomplete and irritative. Under the same circumstances, 
loss of faradic contractility of the paralyzed muscles and wasting are likely 
to come on quickly. 

If the affection of the fifth nerve involve only one of its main branches, 
the paralytic symptoms will of course be limited to the distribution of that 
branch. Accordingly, if the ophthalmic division be alone affected, the 
anaesthesia will occupy the front of the forehead, the upper eyelid, the 
conjunctiva, and a part of the mucous membrane and integument of the 
front of the nose; if the superior maxillary branch, the anaesthesia will 
involve the cheek, the lower eyelid, and upper lip, together with the side 
of the nose, a portion of the temple, the interior of the nose, and the 
mucous membrane of the cheek, upper gums, and palate ; if the inferior 
maxillary, the lateral part of the head and face, with the ear, the lower 
lip and gums, the tongue, and the muscles of mastication ; if the motor 
portion, the muscles of mastication only. 

Treatment If the disease be syphilitic, antisyphilitic remedies are in- 
dicated. But in other varieties of organic disease medicinal treatment can 
have but little influence. If the affection be hysterical, or due to inflam- 
mation or other removable causes, faradism or galvanism may be service- 
able in hastening the restoration both of sensation and of voluntary move- 
ment. 

C. Paralysis of the Portio Dura. (Bell's Paralysis.*) 

Causation This may be caused by any lesion implicating the nucleus 

of the seventh nerve in the floor of the fourth ventricle, or involving the 
nerve in any part of its course thence — either as it passes through the sub- 



PARALYSIS OF THE PORTIO DURA. 



997 



stance of the pons, or between its apparent origin and the internal auditory 
meatus, or in its passage along the aqueduct of Fallopius, or just after its 
emergence from the petrous bone. It may be caused : within the skull, 
by either extravasation of blood, inflammatory mischief, or syphilitic or 
other growths ; in its passage through the bone, either by fracture, or by 
morbid growths originating in the bone-substance, or in connection with 
caries of the internal or middle ear, or in consequence of inflammation 
attacking the nerve itself. Externally to the petrous bone, it may be due 
to injury, as sometimes happens to the infant during delivery by the for- 
ceps, or to inflammatory or other lesions of the parotid or other tissues in 
the vicinity. The most common and interesting cause of Bell's paralysis 
is inflammation of the nerve within the aqueductus Fallopii — a condition 
which is readily induced by allowing a draught of cold air to play on the 
side of the face. Hence not uncommonly it is traceable to a railway jour- 
ney in which the patient has been sitting facing the engine and next an 
open window, or results from exposure of one side of the face while sleep- 
ing to a current of air. 

Symptoms and diagnosis Inflammatory, or so-called 'rheumatic' 

paralysis, is generally of rapid development, and is not necessarily attended 
with pain or constitutional disturbance. Yet not unfrequently the draught 
which caused the paralysis causes also earache, or neuralgic phenomena 
referable to the fifth nerve. The symptoms of Bell's palsy are very strik- 
ing: all the muscles supplied by the seventh of one side are more or less 
completely paralyzed ; the half of the face, consequently, is without motion 
and expressionless ; the wrinkles are smoothed away ; and the predominant 
action of the opposite muscles draws the mouth more or less powerfully 
over to that side. When the patient wrinkles his forehead in surprise, the 
healthy half becomes, through the agency of the occipito-frontalis, trans- 
versely furrowed ; when he frowns, the corrugator supercilii contracts 
the same part into vertical folds ; but in both cases the forehead on the 
affected side remains perfectly smooth. The orbicularis palpebrarum 
ceases to act, so that the eye remains permanently open, and the conjunc- 
tiva, from the loss of its habitual protection, becomes watery and inflamed. 
M. Duchenne points out that this condition is sometimes associated with 
epiphora, and he attributes this circumstance to the fact that the tensor 
tarsi is then paralyzed as well as the orbicularis itself, and consequently 
fails to retain the puncta in the position best adapted for carrying off the 
lachrymal secretion. The ala of the nose gets flaccid, and the correspond- 
ing nostril loses its rotundity. The cheek is motionless, and smooth and 
limp ; the natural furrow beneath the eye and that descending from the 
side of the nose become indistinct ; and when the patient coughs or blows 
through his mouth, the cheek, owing to paralysis of the buccinator, under- 
goes momentary distension. The mouth is drawn to the opposite side ; 
when it is shut, the paralyzed half closes less perfectly than the other ; 
when it is opened, that half open less completely ; and the more power- 
fully he exercises his facial muscles, as in laughing and crying, the more 
extreme does its lateral distortion become. He has lost the power of 
whistling, and probably that of blowing out a candle ; his utterance is 
somewhat impaired ; he has difficulty in retaining fluids in his mouth, 
especially in the act of drinking ; and food tends to collect between the 
teeth and the paralyzed buccinator. There is no anaesthesia. 

There are some important distinctions between paralysis due to direct 
implication of the portio dura, and paralysis of the same nerve of hemi- 



998 



DISEASES OF THE NERVOUS SYSTEM. 



plegic origin. In the first place, in hemiplegia the paralysis rarely involves 
materially those branches of the portio dura which are distributed to the 
eyelids and upper half of the face, while in the primary affection of the 
nerve the paralysis is general. In the second place, in hemiplegia not only 
is there more or less general unilateral palsy, but the motor branch of the 
fifth pair and the hypoglossal are generally involved together with the 
facial ; while, in the other case, the temporal, masseter, and pterygoids 
still act perfectly, and the movements of the tongue are in no degree com- 
promised. Lastly, in hemiplegia the facial paralysis is rarely absolute even 
in the parts chiefly afTected, and the paralyzed muscles retain their bulk 
and faradic contractility, while in Bell's paralysis the loss of power is 
usually absolute, and the muscles lose their electrical contractility very 
rapidly, sometimes in less than a week. In neither case are the muscles 
of the eyeball and the levator palpebral implicated. 

The phenomena above enumerated are those which most commonly at- 
tend Bell's paralysis, and are the only ones which attend it when the lesion 
causing it is situated below the junction of the portio dura with the Vidian 
nerve ; but other phenomena are apt to be superadded in proportion as the 
disease causing paralysis approaches nearer and nearer to the origin of the 
nerve. If the disease be so situated as to involve the chorda tympani 
and petrosal nerves, the patient is likely to suffer : first, from more or less 
over-acuteness or painfulness of hearing, which has been attributed to re- 
laxation of the membrana tympani from paralysis of the tensor, but is by 
Brown-Sequard believed to be due to hyperesthesia of the auditory nerve 
dependent on involvement of the sympathetic branch supplying its blood- 
vessels ; second, from dryness of the half of the tongue corresponding to 
the paralyzed half of the face, and some impairment of taste, owing to 
implication of the chorda tympani and consequent interference with the 
salivary secretion, and to some obscure influence exerted directly on the 
tongue; and, third, from paralysis of the corresponding half of the soft 
palate, resulting from implication of the petrosal nerves. This paralysis 
is revealed : partly by the fact that from involvement of the corresponding 
half of the azygos uvulae, the uvula when at rest, and still more when in 
motion, is so curved that its point is directed away from the paralyzed side; 
and partly by the condition of the corresponding arch of the fauces, which 
is usually a little lower than its fellow, and owing to the tonic action of 
the muscles on the healthy side is drawn over in that direction. 

When Bell's paralysis is due to disease situated within the skull, various 
other complications are liable to be associated with it ; and our diagnosis 
of the seat of the disease will be mainly determined by the nature of these 
complications. Thus if the disease be within or near the internal meatus, 
the auditory nerve is likely to be involved and deafness to be produced ; 
if it implicate the common nucleus of the sixth and portio dura, paralysis 
of the external rectus will go along with the facial palsy ; and if it be 
irregular in distribution, or involve any considerable space, various other 
paralyses, referable to implication of the nerves originating in the floor of 
the fourth ventricle, are liable to be present. 

Occasionally both facial nerves are simultaneously afTected, or affected 
within a short time of one another — a condition which may involve some 
difficulty of diagnosis. 

The prognosis of paralysis of the portio dura will depend on the nature 
of the lesion to which it is due. That form of the disease which results from 
exposure to cold for the most part ends favorably, sometimes in a week or 



PARALYSIS OP THE SPINAL NERVES. 



999 



two, more frequently after four or five weeks, occasionally only after the 
lapse of some months. An element in the prognosis is the condition of the 
paralyzed muscles as to faradic contractility ; the more completely this has 
become annulled, the longer will recovery be delayed, and the greater is 
the fear that the paralysis may be incurable. M. Duchenne draws atten- 
tion to the fact that not unfrequently permanent contraction of the muscles 
previously paralyzed takes place, and that thus consecutive deformities are 
induced. This happens he says in those cases especially in which, either 
spasms supervene in the paralyzed muscles under the influence of faradism 
or other forms of excitation, or a rapid return of tonic force takes place in 
muscles remaining paralyzed and irresponsive to faradism. The contrac- 
tion affects sometimes one, sometimes several muscles. When it involves 
the lesser zygomatic it curves and deepens the naso-labial line and gives 
an expression of chagrin ; when the greater zygomatic, it elevates the 
commissure of the mouth and imparts an aspect of gayety; when the quad- 
ratus menti, it depresses and everts the lip ; when the orbicularis palpe- 
brarum, it causes diminution of the palpebral aperture ; if all the muscles 
are involved, the side of the face becomes wrinkled, as if by cold. At the 
same time that the muscles contract, or it may be subsequently, they usually 
recover their voluntary power ; but that is not always the case, and the 
contracted muscles may remain permanently paralyzed. 

Treatment In the treatment of paralysis of the seventh pair from cold, 

it is generally well (considering the serious results of permanent deformity) 
at once to adopt active measures ; to apply a few leeches to the mastoid 
process, and to follow them up by fomentations, poultices, or equivalent 
applications. Subsequently blisters or other counter-irritants may be re- 
sorted to. If recovery do not follow these measures, electricity should be 
employed. Duchenne thinks it best in cases where the faradic contrac- 
tility has wholly disappeared, to delay the use of faradism until after the 
lapse of two or three weeks. He recommends the employment of a cur- 
rent with rapid intermissions, and that the muscles should be directly and 
in turn excited. He points out that under this treatment the paralyzed 
muscles often regain their tonic power, and the face its symmetry in repose, 
two or three weeks or more before there is any indication of the return of 
voluntary power ; and that it is usually in the zygomaticus major that this 
power first returns — a fact which may be ascertained by making the patient 
smile. When the muscles begin to contract, he recommends that the 
intermissions should be few and the sittings short and unfrequent ; and 
especially he recommends this, if any of the precursory signs of perma- 
nent contraction manifest themselves, in order that such contraction may 
be prevented. Galvanism also is efficacious in restoring the paralyzed 
muscles. 

D. Paralysis of the Spinal Nerves. 

Causation Paralysis of these nerves may arise under various condi- 
tions ; but we propose to refer only to those varieties which M. Duchenne 
speaks of as paralyses from cold, and in which the paralysis is due to in- 
flammation of the trunk of the affected nerve. These affections are not 
uncommon, and may be readily mistaken for ordinary rheumatism. 

Symptoms and diagnosis The symptoms comprise pain and tender- 
ness along the affected nerve and febrile disturbance, together with the 
various consequences of disease involving mixed nerves : namely, on the 



1000 



DISEASES OF THE NERVOUS SYSTEM. 



one band, burning or shooting pains in the course of its branches and 
hyperesthesia followed by tingling and numbness ; on the other hand, 
muscular paralysis, followed by speedy loss of faradic contractility and 
wasting. The muscular paralysis for the most part comes on later than 
the sensory symptoms. During the early period of the disease, the tem- 
perature of the affected parts is augmented, later on it undergoes manifest 
diminution. 

M. Duchenne singles out two forms of this affection for description, one 
of which he terms ' deltoid rheumatism,' the other ' paralysis of the radial 
nerve.' Affection of the spinal accessory is also not uncommon. 

1. Deltoid rheumatism is essentially inflammation of the circumflex nerve. 
It is marked by the occurrence of violent neuralgic pains in the deltoid 
muscle, sometimes coming on in paroxysms, and augmented by any move- 
ment of the shoulder. In voluntary movements pain is especially excited 
in those fibres which are brought into contraction — a circumstance which 
will help to distinguish deltoid rheumatism from ordinary articular rheu- 
matism. The symptoms may last for a few days only, or be prolonged for 
months. In many cases convalescence takes place without the occurrence 
of complications ; but in some cases, atrophy of the deltoid, or of a part of 
it, supervenes after the pains have continued for some time ; and when at 
length, under these circumstances, the pains have subsided, the muscle 
continues atrophic, although retaining its voluntary and electric contractility. 
In other cases paralysis, attended with more or less complete abolition of 
faradic contractility, supervenes. 

2. Paralysis of the radial or m?isculo-spiral nerve is sometimes referred 
to pressure on the nerve, occurring, for example, during sleep, but by M. 
Duchenne is attributed (like Bell's paralysis) to exposure to cold, especially 
to exposure of the arm during sleep to a current of cold air, or to cold and 
damp. It generally comes on suddenly, without pain or tenderness, but 
with numbness and tingling, extending to the tips of the fingers. The 
paralytic symptoms have a close resemblance to those of lead-poisoning, 
and, like these, comprise, as an essential feature, dropping of the hand, and 
incapability of extending the fingers. The differences between them arc, 
as M. Duchenne points out: first, that in paralysis from cold, the paralyzed 
muscles retain their electrical contractility unimpaired, whereas in lead- 
palsy this quality rapidly diminishes or disappears ; second, that the supi- 
nator longus, which never suffers in lead-poisoning, is invariably implicated 
in the present case. The following, as is shown by M. Duchenne, is the 
proof of implication of this muscle : — namely that when the patient has 
placed his forearm in the position of semiflexion and semi-pronation, and 
attempts to flex it more completely (the attempt being opposed) the long 
supinator, which in that position is the flexor of the forearm, can be neither 
seen nor felt to contract. As in lead palsy, the flexor muscles of the fore- 
arm and hand and the interossei escape. Paralysis of the musculo-spinal 
nerve from cold is almost always followed sooner or later by recovery. In 
some cases, however, progressive wasting of the affected museles comes on ; 
and occasionally, also, the opposing muscles and the interossei become 
manifestly enfeebled from want of use. 

Treatment. — The value of electricity in the treatment of the above forms 
of paralysis is very great. When the deltoid pains are unattended with 
fever or local signs of inflammation, M. Duchenne strongly recommends 
the use of cutaneous faradism, effected upon a dry surface, with a feeble 
and slowly intermittent current. When, however, there is wasting or 



LOCAL FUNCTIONAL SPASM AND PARALYSIS. 



1001 



paralysis, faradism of the muscles or the interrupted galvanic current is 
especially indicated, both in the case of the deltoid and in that of the mus- 
cles of the forearm. In both cases moreover, frictions, stimulant appli- 
cations, and blisters are often serviceable. When there is distinct evidence 
of inflammation, the various forms of electricity are not only inefficacious, 
but injurious. The ordinary remedies for local inflammation are then 
called for. 



XXI. LOCAL FUNCTIONAL SPASM AND PARALYSIS, 
WRITER'S CRAMP, WRY-NECK, HISTRIONIC SPASM, &c. 

Definition The affections here referred to are limited to a single mus- 
cle, or part of a muscle, or to groups of muscles, and occur only or mainly 
at the time when certain accustomed specific actions in which they are en- 
gaged are in process of performance — the affected muscles apparently acting 
normally under all other conditions, and in other respects seeming fairly 
healthy. 

Causation The causes of these functional derangements are exceed- 
ingly obscure. They are, however, for the most part induced by the long- 
continued exercise, in special motor combinations, and the consequent 
fatigue, of the muscles which afterwards become affected. 

Symptoms and diagnosis — The n?">3t common of the affections included 
in the present group are those which ^re known in this country as 'writer's 
cramp,' or 4 scrivener's palsy,' and 4 spasmodic torticollis,' or 4 wry-neck,' 
and ' histrionic spasm.' 

1. Writer's cramp affects, as its names imply, those who are engaged 
in writing, and more especially those whose avocations compel them to 
write for many hours a day continuously for long periods of time. It gen- 
erally commences with a sense of fatigue or pain in certain of the muscles 
of the hand or forearm, which comes on shortly after the patient has begun 
to write. This condition increases slowly until pain or weariness attends 
all his attempts to write, and compels him to rest for a time or to desist 
altogether. Sooner or later, and sometimes from the very commencement, 
some spasm or loss of power, coming on only when the patient is engaged 
in writing, seizes certain of the muscles which he is exercising, and ren- 
ders his handwriting tremulous or jerky or arrests his operations completely. 
In the earlier stages of the disease, the patient sometimes resists its influence 
with more or less success. But its almost inevitable tendency is to go on 
from bad to worse, until at length the use of the pen becomes impossible. 
In some cases patients have learnt to write with the left hand; but in many 
of these, unfortunately, this hand has after a while become affected simi- 
larly to the other. 

The affection is sometimes paralytic, the patient suddenly losing power 
over certain muscles, and dropping the pen from his hand; in most cases 
it is spasmodic, the muscles causing tremulous or choreic movements, or 
sudden flexion, extension, or rotation. Different muscles are affected in 
different cases. In some instances they are the extensors and flexors of 
the index finger ; in some the interossei of the second and third fingers ; 
in some the muscles of the thumb ; in some the supinators of the hand. 
Occasionally the muscles of the hand and forearm are all more or less in- 
volved. In some cases the spasm or paralysis commences in the deltoid or 



1002 



DISEASES OF THE NERVOUS SYSTEM. 



other muscles of the shoulder ; and in some it extends from the muscles 
of the hand and arm to those of the head and neck and trunk. As a rule 
more or less sense of fatigue or pain accompanies the functional motor dis- 
turbance, but occasionally the patient complains of muscular cramp or of 
neuralgic pains. However extreme the paralysis or spasm becomes, the 
muscles retain their functional activity for all other movements than those 
which have induced them ; but there is for the most part distinct loss of 
muscular power. 

2. Spasmodic wry-neck is an affection of adult life, and of either sex. 
It comes on for the most part insidiously with uneasiness or pain in the 
affected side, and a tendency to jerk the head as though to relieve some 
feeling of discomfort. By degrees the uneasiness increases, the spasmodic 
movements become more constant and more violent, and the head is habitu- 
ally carried on one side. At first the patient can temporarily restrain his 
spasms by a voluntary effort, and temporarily holds his head erect, or he 
can counteract the spasmodic contraction of the affected muscles by the 
voluntary action of the healthy muscles of the opposite side. But after a 
while the head and neck become permanently twisted, and the clonic spasms 
which accompany this twisting are beyond even temporary control. The 
spasm of the muscles of the neck is apt to become associated with similar 
spasm of the facial muscles or of those of mastication, or of those of the 
shoulder or arm. In the great majority of cases the spasms cease during 
sleep, or whenever the head is supported. 

The muscles which are affected differ in different cases. In some in- 
stances they are those which rotate the atlas and skull upon the axis, and 
the movements of the head are those of simple rotation. Sometimes it is 
the splenius capitis which suffers ; in which case the head is inclined down- 
wards and backwards towards the affected side, the face at the same time 
rotating towards the same side, and the skin of the side of the neck being 
thrown into deep transverse folds. Sometimes it is the clavicular portion 
of the trapezius which is implicated ; in which case, as in the last, the 
head is inclined downwards towards the affected side, and thrown some- 
what backwards, but the face is rotated towards the opposite side. If the 
fibres of the trapezius which are attached to the shoulder also are involved, 
the shoulder will be distinctly elevated. Sometimes the sternomastoid 
suffers ; in which case, as when the trapezius is contracted, the head is 
inclined towards the affected side, and the face is rotated towards the oppo- 
site shoulder ; but, contrary to what happens in either of the other cases, 
the head is thrown forwards. Although the several muscles which have 
just been named may be affected separately, it is more common to find 
groups of muscles implicated. But the affected muscles can generally be 
readily recognized not merely by their effect on the movements of the head, 
but also by their contraction, rigidity and spasmodic action. 

3. Among examples of other similar conditions we may quote the fol- 
lowing, chiefly from M. Duchenne : A tailor whenever he had made a few 
stitches suffered from violent rotation of the arm inwards, in consequence 
of contraction of the subscapular muscle. A fencing-master, whenever he 
put himself into the posture of defence, was seized with rotation of the 
arm inwards and violent extension of the forearm. A turner whenever he 
attempted to work the lathe with his foot, suffered from spasmodic contrac- 
tion of the flexors of the foot upon the leg. A gentleman, who also suf- 
fered from writer's cramp, became subject, when he attempted to read, to 
contraction of the rotator muscles of the head, which carried his head to 



NEURALGIA. 



1003 



the right. A literary man, who had been employed for some years in 
deciphering manuscripts, suffered after a while from double vision, coming 
on a few seconds after he had fixed his eyes intently on any object ; the 
defect was due to spasmodic contraction of one of the internal recti. A 
student, who had overworked himself, became the victim of a strange 
affection which rendered reading impossible, and finally impelled him to 
commit suicide. As soon as he began to read, he was seized with a pain- 
ful constriction of the forehead, temples, and eyes, during which the eye- 
brows were elevated by spasmodic contraction of the frontales, and the 
eyes closed by the powerful action of the orbiculares palpebrarum. Pian- 
ists are liable to the same affection as writers are. Singers occasionally 
become incapable of singing from involvement of the laryngeal muscles ; 
soldiers of marching from implication of the peroneous longus. In some 
cases the spasms affect the muscles of expression (histrionic spasm), in 
some the platysma, in some the muscles of mastication, and in some those 
of respiration. 

Pathology. — The pathology of these functional affections is very obscure. 
Most writers believe that the primary fault is in the nervous centres; but 
Dr. Poore, in his able text-book of electricity, seems to prove conclusively 
that the disease is in many cases due to abuse of the implicated muscles, 
which ' become tired out, and degenerate into a condition of chronic fatigue 
or irritable weakness ;' and he shows also that, contrary to the general 
belief, the affected muscles are absolutely weaker than their healthy fel- 
lows, and that their faradic irritability is diminished. 

Treatment has not usually proved satisfactory. In Duchenne's hands 
faradism failed absolutely. Dr. Poore, however, has latterly obtained 
great success by the employment of the continuous current in combination 
with rhythmical exercise of the enfeebled muscles. His mode of using the 
current in writer's cramp is as follows: 'One pole (the positive) is placed, 
let us say, in the axilla, and the other over the ulnar nerve, just where it 
leaves the edge of the biceps muscle en route for the olecranon. The 
strength of the current is short of that which causes muscular contractions, 
but is just sufficient to make the patient conscious of a tingle in the end 
of the little finger when the circuit is made or broken. The patient is 
then made to exercise the interossei by separating and approximating the 
fingers rhythmically.' The nerve to be galvanized and the muscles to be 
exercised will of course differ in different cases. Liniments and douches 
may also be employed : and tonics are generally indicated. But in all 
cases it is of the highest importance for the patient to abstain in a greater 
or less degree from all those habitual actions with which the muscular 
default is especially linked, and never to attempt to overcome it by violent 
efforts. Rest is essential. 



XXII. NEURALGIA. TIC DOULOUREUX. SCIATICA. 

Definition — By the term neuralgia is meant pain, for the most part 
paroxysmal, occurring in the course of the nerves and in their arese of dis- 
tribution. 

Causation — Neuralgia is the result of numerous different conditions. 
It may depend on injuries to nerves, due to contusion, laceration, or the 



1004 



DISEASES OF THE NERVOUS SYSTEM. 



impaction of foreign bodies; on pressure, such as may take place when the 
bony channels through which certain nerves pass become contracted from 
any cause, or when nerves are pressed upon by tumors or other adventi- 
tious masses ; or on the implication of nerves in disease, as, for example, 
when they are involved in rheumatic or other inflammations, in syphilitic 
gummata, or in carcinomatous or other tumors. In some cases it appears 
to depend upon, or to be connected with, certain constitutional conditions, 
such as the malarial cachexia, anaemia, and hysteria. In a considerable 
number of cases no cause whatever, local or constitutional, can be dis- 
covered. Neuralgic affections are said to be hereditary. This is no doubt 
true of specific forms, such as megrim, and possibly of tic, but can scarcely 
admit of satisfactory proof in respect of the heterogeneous cases which make 
up the great bulk of ordinary neuralgias. 

It need scarcely perhaps be pointed out that neuralgic pains, which are 
sometimes of extreme intensity, attend a large number of the diseases 
which have already been discussed ; among others, tabes dorsalis, spinal 
caries, and more particularly carcinoma of the vertebras or pelvic organs, 
certain inflammatory affections of deep-seated parts, such as abscess of the 
liver, calculous pyelitis, and hip-joint disease, and a large proportion of 
the cases of zona or herpes zoster. 

Lastly, it is important to bear in mind that the lesion or local condition 
causing neuralgia may exist in the course of the implicated nerve, or in 
the spinal cord or brain, or (as above pointed out) may occupy some 
remote part from which it acts indirectly. 

[In this connection it is proper to introduce some reference to the views 
held by the late Dr. Anstie in regard to the pathology of neuralgia. In 
his opinion the morbid process, which consists in an atrophic change, was 
seated in the posterior roots of the spinal nerves or in the gray matter with 
which these are connected. The atrophy may be preceded by inflamma- 
tion, but this is not necessary, as it may be produced by long-continued 
alteration in the nutrition of the part, caused by peripheral irritation of 
the nerves. The amount of positive evidence in favor of this view, it must 
be confessed, is small ; there exists, however, at least one observation 
tending to confirm it. In a case reported by Romberg, a man had suffered 
for several years from the most violent and intractable trigeminal neuralgia 
complicated with interesting trophic changes of the tissues. Post-mortem 
examination showed that the pressure of an internal aneurism had almost 
entirely destroyed the Casserian ganglion of the painful nerve, that the 
trunk and posterior root of the nerve were in a state of advanced atrophic 
softening ; and that the atrophic process had extended in a less degree to 
the nerve of the other side. Moreover, in locomotor ataxia, in which the 
main anatomical change is a progressive atrophy of the posterior columns, 
which usually involves the posterior nerve-roots, and which may extend 
to the gray matter immediately adjoining them, neuralgia may be said to 
be a constant and most characteristic phenomenon.] 

Symptoms and progress. — Neuralgia is characterized essentially by the 
occurrence of pain in the course and distribution of some one or more of 
the sensory nerves. The pain varies in character : it may be tingling, 
aching, burning, boring, crushing, cutting, stabbing, darting; it may be 
more or less continuous, but usually occurs in sudden lightning-like shocks, 
which come on either singly or in paroxysms made up of a larger or 
smaller number of such shocks ; and even when it is continuous it is 
usually attended with exacerbations presenting more or less of the latter 



NEURALGIA. 



1005 



character. The pain varies also in intensity ; in its severest paroxysmal 
form the patient's sufferings are horrible — sometimes he raves and stamps 
like a madman, sometimes utters half-suppressed groans, sometimes screams 
aloud ; but under any circumstances is so absorbed in the intensity of his 
sufferings that he appears almost unconscious of every thing which is going 
on about him ; on the other hand, it may consist in nothing more than a 
little tingling, creeping, or burning. This is often the case during the 
interparoxysmal stage of those cases in which there is never entire cessa- 
tion from pain ; and such sensations often constitute the commencement of 
each paroxysmal attack. 

It very commonly happens that more or less tenderness or hyperesthesia 
is associated with neuralgia ; there may be tenderness along the course of 
the affected nerve ; or there may be general tenderness in the area of its 
distribution, or spots of special tenderness scattered here and there upon 
that surface. It is a fact of considerable importance, first established by 
Valleix, and since confirmed by numerous observers, that in neuralgia 
there are generally, if not always, specially painful spots, which are more 
or less characteristic for each nerve that may be involved, and are deter- 
mined mainly by the emergence of the nerve or some of its branches from 
a bony canal, or by their passage through some dense fascia. Trousseau 
insists that one of these painful spots is the spinous process of that portion 
of the spine from which the painful nerve escapes. The neuralgic paroxysm 
may often be induced by irritation of the hypersesthetic parts, or even by 
touching them ; on the other hand, firm pressure upon them may relieve 
or avert it. 

Anaesthesia, again, is not unfrequent in connection with neuralgia. 
Sometimes more or less impairment of tactile sensibility or discrimination 
goes along with considerable tenderness or hyperesthesia. But absolute 
loss of sensation in the affected area occasionally supervenes after a time. 

The sudden darts of intense pain which so commonly attend neuralgia 
are generally associated with more or less sudden reflex movements or 
twitchings of the parts affected ; if the toe be attacked, the leg is momen- 
tarily drawn up by an uncontrollable impulse; if the finger, the arm; if 
the face (as in ordinary tic douloureux) spasmodic twitching of the mus- 
cles of the painful region occurs. These convulsive movements may vary 
from mere twitching of the muscles to spasmodic contractions of consider- 
able force. 

The above phenomena are apt to be complicated with other local mani- 
festations. In many cases the affected surface becomes during the occur- 
rence of the paroxysm more or less red and congested ; and not unfrequently 
obvious dilatation of the arteries and veins both in, and leading to or from, 
the implicated region takes place, attended with painful throbbing. In 
connection with congestion, there is apt also to be some temporary modifi- 
cation of function in the affected area, such as arrest or increase of secre- 
tion, which is especially obvious if the conjunctiva or the mucous membrane 
of the nose or mouth be the part involved. 

Further, the various nutritive lesions, especially erythematous and 
herpetic eruptions, which have previously been referred to affections of 
the sensory nerves, are all apt to occur in connection with neuralgia. 
Occasionally also the hair over the affected region turns temporarily or 
permanently white. 

An interesting feature of neuralgia is the tendency to shift which it 
presents in many cases. Thus in trifacial neuralgia the paroxysmal attacks 



1006 



DISEASES OF THE NERVOUS SYSTEM. 



not unfrequently wander either from day to day, or it may be at distant 
intervals, from one branch of the nerve to another branch; the pain may 
even pass over to the great occipital nerve or to branches of the cervical 
or brachial plexus. 

Another important point connected with neuralgia, and one indeed 
which has been regarded as inseparable from true neuralgia, is its unilate- 
ral or unsymmetrical character. This characteristic, however, is not uni- 
versal, and occasionally both arms or both legs are symmetrically and 
equally affected. 

In a large proportion of cases neuralgia is essentially intermittent ; the 
pains come on in paroxysms lasting probably from a second or two to a 
minute, rarely longer, which recur every five or ten minutes, day and 
night, or manifest themselves at longer and more or less irregular inter- 
vals. Occasionally they remit for weeks or months together. 

The general state of health of neuralgic patients presents considerable 
diversity, yet it is important in reference both to prognosis and to treat- 
ment to pay attention to this subject. Thus in some cases we find the 
patient anaemic, in some hysterical, in some laboring under the conse- 
quences of old syphilis ; sometimes he is rheumatic, sometimes gouty, 
sometimes he is suffering from the effects of the malarious poison. But 
in a considerable number of cases, and these are often the most severe and 
intractable, no general morbid condition can be discovered beyond that 
which the persistent neuralgia itself induces. In these cases the disease 
is not unfrequently incurable. 

Neuralgia may attack any of the sensory nerves, as well those supply- 
ing the viscera as those distributed to the skin. Among the former class 
may especially be named neuralgiae of the heart, stomach, kidneys, uterus 
and ovaries, testes, and mammae. Among the latter class the more im- 
portant probably are trifacial neuralgia or tic douloureux, and sciatica. 

1. Tic douloureux, or as Trousseau terms it, epileptiform neuralgia, is 
at once the most severe and the most typical variety of neuralgia. It 
comes on in adult life, and is for the most part of lifelong duration. Its 
causes are obscure : sometimes it is referred to carious teeth, sometimes to 
exposure to cold, sometimes to gastro-intestinal irritation, sometimes to 
old age or failing health or malarious influence. The neuralgic phenomena 
involve the branches of the fifth nerve of one side. In some cases it is 
the first division, in some the second, in some the third, occasionally the 
whole nerve; or it may be that certain portions only of its divisions 
are involved. The pains, moreover, are apt to shift from time to time 
from one division to the other, or from certain fibres to certain other 
fibres. They vary in character as other neuralgic pains vary ; but usually 
are burning or shooting, and occur in sequences of sudden electric-like 
shocks. They vary also in intensity, from a mere sense of warmth or 
tingling to paroxysms of the most intense agony. They sometimes come 
on at rare intervals; sometimes, on the other hand, occur every few 
minutes, night and day, and are then apt to be brought on by any move- 
ment of the affected parts, by pressure, by a sudden shock, or even by a 
breath of cold air. Consequently, in cases in which the second or third 
division is involved, the patient finds it impossible to masticate, and 
almost impossible to take nourishment by the mouth. Under any circum- 
stances the severity and frequency of the paroxysms are apt to vary from 
time to time ; and occasionally, even in severe cases, the attacks intermit 
for comparatively short periods. In aggravated cases the paroxysms of 



NEURALGIA. 



1007 



pain are often attended with spasmodic contractions of the muscles of the 
affected region. Sometimes the patient smacks his lips, or chews, or exe- 
cutes other movements which are apparently voluntary, and are per- 
formed with the object of relieving pain. More frequently he rubs his 
face during the paroxysms either with his hand or a handkerchief, or with 
a pad that he carries in his hand for the purpose. This constant rubbing 
not unfrequently wears down the hair of the affected side — the whisker, 
the beard, the hair in the neighborhood of the temple — which then appears 
as if kept close shaven; occasionally it even modifies the form of the side 
of the face. Further, the frequently repeated spasmodic action of the 
muscles of the affected side produces after a while a permanent curiously 
wrinkled condition of the surface. 

Tic douloureux, unbearable though it appears to be, does not tend directly 
or necessarily to shorten life. Patients nurse their agony for many years. 
The only ways in which it can be regarded as inimical to life are by the 
difficulty which it occasionally opposes to the ingestion of food, and by 
driving the patient to suicide. 

2. Sciatica. — This is one of the most common varieties of neuralgia. 
It frequently arises from exposure to cold, but may be due to many other 
causes ; it is occasionally attended or followed by some degree of anaes 
thesia, and occasionally, but mainly when due to structural diseases, leads 
to wasting of the muscles. The pain is of true neuralgic character, and 
is greatly aggravated by movement of the implicated limb, or by pressure. 
It is in many cases exceedingly persistent and difficult of cure. 

Treatment In dealing with cases of neuralgia it is always of great 

importance to ascertain, if possible, the cause on which it depends, and 
then if it be within our competence, to obviate or remove it. If, for ex- 
ample, the pain be traceable to the influence of the malarious poison, qui- 
nine or arsenic is indicated ; if it be connected with anaemia, iron is prob- 
ably the best remedy; if it be a consequence of exposure to cold or rheu- 
matism, the treatment suitable for these conditions should be employed; 
if it be referable to syphilis, iodine and mercury are most likely to be 
serviceable ; and further, if it depend on the existence of some local mor- 
bid process compressing or otherwise involving the nerve, our treatment 
must vary accordingly. 

Rut in a large number of cases, no such hints for treatment are afforded 
us ; we can then, so far as general treatment is concerned, only deal with 
them empirically. Among remedies which, under these circumstances, 
have been found useful, may be enumeiated iron, arsenic, quinine in large 
doses, oil of turpentine, chloride of ammonium, phosphorus, croton-chloral 
hydrate, aconite, Indian hemp, belladonna, and opium. Of these, opium, 
or its alkaloid, morphia, is by far the most valuable. Indeed, the severest 
cases of tic, and of similar forms of neuralgia in other parts, often find 
relief only from large and repeated doses of this drug, which may then be 
given by the mouth, or, preferably, by subcutaneous injection. If given 
by the mouth, it may be necessary at length, having begun with small 
doses, to administer as much as from twenty to sixty grains of morphia 
daily. Alcohol is not unfrequently serviceable in relieving pain. Cases 
of the less severe forms of neuralgia are occasionally cured by a few glasses 
of wine, or by a tumbler of strong brandy and water. 

Local medication is often very valuable. Of course the several nar- 
cotics which have been enumerated, especially morpia and atropia, may 
be injected subcutaneously at the seat of pain. But, besides this, the 



1008 



DISEASES OF THE NERVOUS SYSTEM. 



application to the surface, or the inunction, of opium, belladonna, or aco- 
nite, often gives relief. The most valuable of these applications is aconite 
in the form of the unguentum aconitiag. Counter-irritation also is fre- 
quently of much benefit, more especially by means of blisters, issues, the 
actual or galvanic cautery, and acupuncture. Electricity is especially 
valuable. Duchenne employed cutaneous faradism, rendering the affected 
surface dry by dusting it with some powder, and then applying to it for a 
minute or so faradism of considerable strength, and repeating the process 
from time to time, according to circumstances. But the continuous current 
is much more efficacious. In this case well-wetted sponges must be used, 
and the current employed must be of no greater intensity than the patient 
can readily bear; and, as has been before pointed out, the origin of the 
affected nerves should be included between the rheophores, of which one 
should be moved over the painful region, and especially applied to the 
painful points. Moreover here, as in the other cases, the applications 
should be of short duration, and frequently repeated. Lastly, division of 
the affected nerve has often been practised, especially in cases of tic dou- 
loureux. It cannot be asserted that this procedure ever absolutely cures 
the neuralgia ; but there is no doubt it very often effects a temporary cure 
— a cure lasting occasionally for a few weeks or even for several months. 



XXIII. INSANITY. 1 

Definition When under the shadow of some great calamity a man 

becomes depressed and sad, when under the influence of recurring petty 
annoyances he gets irritable and quarrelsome, when unexpected prosperity 
or long-deferred hopes suddenly gratified makes him happy and buo} T ant 
beyond measure, the frame of mind which he presents, however foreign 
to his usual habit, is rightly regarded as normal. But when without ob- 
vious or sufficient cause, or it may be under circumstances apparently 
calculated to have an entirely opposite effect, the mind becomes tempora- 
rily gloomy and sad, or inclined to resent alike injuries and efforts to 
please, or unduly excited and jovial, there is no doubt that the mental 
condition is unnatural and morbid. Yet no one would venture to suggest 
that such phenomena, which are of frequent occurrence even amongst the 
healthiest of us, and are often connected with passing phases of ill-health, 
are necessarily evidences of insanity in the usual acceptation of that term. 
Again, it is of common experience that certain expressions or sounds, or 
visions, or thoughts, originating probably in some occurrence or journey 
which has impressed us, are from time to time apt to haunt the perfectly 
healthy mind, to obtrude themselves at inopportune moments and to cause 
annoyance and distress by their iteration. Such occurrences can scarcely 
be regarded as abnormal ; but when oaths and blasphemy obtrude upon 
the mind as the sufferer kneels at his prayers and at length the very 
thought of praying becomes torture to him, when the vision or thought of 
murder or accidental death constantly rises before him, and he dreads to 

1 In writing this article the authors who have been chiefly consulted, and whose 
language has here and there been employed, are Griesinger, Marce, Maudsley, 
and Bucknill and Tuke. 



INSANITY. 



1009 



have a weapon at hand for fear he shall be impelled to use it, or to cross a 
bridge or travel by train lest he be drowned or smashed, his mental condi- 
tion is clearly unhealthy, and yet again ' insanity' is not necessarily 
present. So also when a patient wholly ignorant of the structure and 
functions of his body assumes some preposterous explanation of his malady, 
and believes it — when the sufferer from dyspepsia ascribes his discomfort 
to the presence of a swarm of bees in his abdomen, or the man who has 
been living in chastity refers any uncomfortable feelings in his head to 
accumulation of semen in the brain, absurd though the delusion is, it does 
not necessarily imply insanity even though it impels him to have recourse 
to outrageous measures for his relief. Yet the unhealthy moods and con- 
ditions of mind here enumerated are such as constantly precede an out- 
break of insanity ; their persistence is not unfrequently the only proof we 
have of the presence of actual insanity ; and under any circumstances it is 
but a step from causeless moodiness to melancholia, from inexplicable 
vivacity to mania, from the foolish fancies of a weak or hypochondriacal 
intellect to the delusions of monomania, from the pestilent thoughts and 
impulses which rise unbidden to the mind to the sudden commission of acts 
which indicate the impulsive or instinctive lunatic. 

To pass on to another series of considerations. Delirium and mental 
failure in various forms are the constant consequences of many diseases 
and morbid states of the system in which the brain is only secondarily im- 
plicated. In cases of poisoning, as by alcohol, opium, or belladonna; 
where effete matters are retained in the blood, as in uraemia, and in the 
typhoid condition; in many febrile diseases, such as typhus, smallpox, 
scarlatina, and enteric fever ; in inflammatory disorders, as for example 
in erysipelas and catarrh; in pneumonia, rheumatism, and pyaemia; 
after profuse losses of blood; and under innumerable other circumstances, 
the patient is apt to become incoherent and forgetful, to suffer from hallu- 
cinations and delusions, to present an aspect of dulness, suspicion, or ex- 
citability, and to be troublesome, noisy, or violent in his manner. Now 
the group of mental disturbances here referred to are not ordinarily re- 
garded as insanity, or described in works devoted to this department of 
medicine. Yet cases of so-called ' delirium' present as many different 
varieties as true insanity does ; the differences between delirium and insanity 
are differences of degree and proportion and not of kind, nor excepting in 
the circumstances under which the mental disturbance arises is there 
anything by which cases of delirium can necessarily be distinguished 
from cases of insanity. 

Once more, a child is born with some material cerebral defect and grows 
up an idiot; a man who has exceeded the allotted span of life becomes, in 
connection with disease of his cerebral arteries, childish and imbecile ; or a 
person who has a syphilitic or other tumor of the brain lapses into fatuous- 
ness and presents delusions. Now it is impossible to deny, judging from 
their clinical aspects only, that such cases are examples of insanity. Yet 
there is an undoubted tendency among alienists to exclude from the defini- 
tion of insanity all cases in which the mental disturbance is the direct 
result of some material lesion. 

It is easy no doubt to enumerate those mental conditions which are not 
ordinarily regarded as insanity, and so to exclude them from the applica- 
tion of any definition we may frame ; but it is very difficult if not impos- 
sible to construct a definition which shall be applicable to all cases of 
insanity, and yet shall not apply equally to other mental conditions. 
64 



1010 



DISEASES OF THE NERVOUS SYSTEM. 



Esquirol's definition is simple, but suffers from this defect. It is as fol- 
lows : 'Insanity is a cerebral affection, generally chronic, unattended with 
fever, and characterized by disorders of sensibility, intellect, and will.' 
Dr. Maudsley, in ' Reynolds's System of Medicine' modifies this definition, 
and declares insanity to consist ' in a morbid derangement, generally 
chronic of the supreme cerebral centres, giving ri«e to perverted feeling, 
defective or erroneous ideation, and discordant conduct, conjointly or 
separately, and more or less incapacitating the individual for his due 
social relations.' To these M. Marce would add 4 that in madness the 
patient is unconscious of his state.' We shall not attempt to improve on 
these definitions. 

Causation. — (a) The question of the influence of race or nationality in 
the causation of insanity has been largely discussed. But the subject is a 
complicated one; for it necessarily comprises, not merely the simple influ- 
ence of race, but the collective influence of all those conditions which 
contribute or have contributed to the formation of the national character, 
such as religion, politics, warfare, occupation, habits, intellectual progress, 
and civilization. And the general result of inquiries with regard to it has 
been to show, not that there is any appreciable difference in respect of 
proneness to insanity among races of men per se, but that insanity is apt 
to become especially rife during great national or religious crises, and 
under other conditions of wide-spread emotional excitement, and that on 
the whole the lower nations are in the scale of education and civilization the 
less the frequency with which insanity occurs amongst them, (b) Hered- 
itary predisposition plays an important part in the production of insanity. 
According to Dr. Maudsley the proportion of distinctly hereditary cases 
to others, is not lower than one-fourth, if not so high as one-half. But 
although the general truth of this proposition has been established beyond 
dispute, it is for many reasons very difficult to give it exact numerical 
expression ; especially it is difficult to decide how far back and how wide 
amongst direct ancestors and collateral relations such influences may prop- 
erly be sought. Again, although actual insanity amongst parents or 
relations is the most frequent cause of hereditary predisposition, it is well 
ascertained that other neuroses, more especially epilepsy, hysteria, and a 
suicidal tendency, have a like influence ; that genius and insanity are often 
distributed in the same family ; that drunkenness in parents is apt to beget 
insanity in children, and that the frequent intermarriage of close relations 
tends sooner or later to a like result. Esquirol observed, and his observa- 
tion has been confirmed, that insanity descends from the mother more 
frequently than from the father, and to the daughters in larger proportion 
than to the sons, (cj Education has an undoubted influence in relation 
to insanity. A judicious training tending to strengthen minds which have 
an inherent weakness and proclivity to insanity, while an injudicious 
training may sow the seeds of mental disease in those who are free from 
all original taint. The subject is a wide and important one; but it is 
sufficient to remark here that long-continued harshness, cruelty, and repres- 
sion in early childhood, the persistent endeavors to cram the undeveloped 
mind with, abstruse or unsuitable knowledge, or to instil with terrifying 
iteration the repulsive dogmas of a narrow Christianity, the foolish and 
indiscriminate yielding to all the whims, selfish desires, and passions of 
childhood, may each in its own way exert an evil influence over the future 
mental welfare of the unfortunate victims, (d) Social position and occu- 
pation are of doubtful efficacy in causing insanity, excepting in so far as the 



INSANITY. 



1011 



J different conditions included under these terms imply exposure to asso- 
i ciated influences which are themselves productive of insanity, such as 
drunkenness and other forms of debauchery, mental strain, emotional dis- 
turbance, and- the like, (e) Sex — There is no sufficient reason for be- 
j lieving that one sex is more liable to insanity than the other. At the 
same time the exciting causes of insanity act with different relative fre- 
quency in the two cases ; and there are marked differences in the degree 
| in which the several forms of insanity prevail among them. Especially it 
i may be noted that general paralysis, which is a common form of the dis- 
j ease in men, is rarely observed in women, (f ) No age can be regarded 
I as exempt from liability to insanity. It is rare before puberty ; yet all 
forms (excepting general paralysis) are occasionally met with during this 
I period of life. It becomes much more common between 16 and 25; but 
• arises mainly between 25 and 45 or 50. In women it is apt to occur with 
special frequency about the climacteric period. Subsequently the tendency 
j to insanity declines. In these remarks in reference to the influence of 
J age, idiocy has been excluded from the one end of the scale and senile 
: dementia from the other. The above are usually regarded as predisposing 
I causes. 

The exciting causes of insanity are of two kinds, namely, the moral or 
1 psychical and the physical, (a) Moral causes are generally held to be 
| the most fertile sources of the disease. Mere intellectual exertion, how- 
ever intense or however much prolonged, rarely produces it. The expan- 
sive passions — ambition, overweening vanity, immoderate joy, and the 
like — are almost equally inefficacious in this respect ; and when they do 
I cause it, operate usually by slow degrees, and, as Dr. Maudsley observes, 
| ' as a gradual development or exaggeration of a particular vice of charac- 
ter.' It is the depressing emotions which are mainly instrumental in 
causing insanity, and Pinel was so convinced of the truth of this, that the 
first question he put to a new patient was always, ' Have you suffered 
vexation, grief, or reverse of fortune?' Fierce anger, unrequited love, 
jealousy, prolonged anxiety, loss of fortune, disappointed ambition, the 
sudden death of some dear relative or friend, remorse, hatred, fright, relig- 
ious depression, the sense of being unequal to responsibilities which have 
been incurred, may be adduced as examples of the kinds of emotions here 
referred to. The effect of such emotions may be sudden, as when they act 
by shock ; or slow, in which case either they produce a gradual intensifica- 
tion of peculiarities already present in the patient's character, or they 
involve a gradual morbid change in one or more of the viscera, to which 
change, rather than to the emotional disturbance directly, the mental disease 
is due. 

(b) The physical causes of insanity — Amongst these, alcoholic intem- 
perance is doubtless the most important. The symptoms of simple ine- 
briation are closely related to those of insanity, delirium tremens is itself 
a variety of insanity, and further, the habit of drinking to excess produces 
irritability, vacillation, and other mental phenomena which indicate dete- 
rioration of mind. But independently of these conditions, partly it may 
be from the emotional disturbances which are incidental to alcoholism, 
partly from the direct influence of alcohol in the production of diseases, 
and especially induration of the surface of the brain, the abuse of drink is 
a pregnant cause of insanity. It operates chiefly in man ; and is the main 
cause of general paralysis of the insane. Intemperance in opium, absinthe, 
Indian hemp, or other narcotics, is also liable to induce insanity. Sexual 



1012 



DISEASES OF THE NERVOUS SYSTEM. 



excess, and especially self-abuse, are well-recognized exciting causes. Self- 
abuse is specially efficacious in this respect, partly from the early age at 
which it generally commences, partly from the excessive frequency with 
which it is apt to be indulged in, but mainly, probably, because of the 
moral distress which a persistence in the habit always occasions. Affec- 
tions of the nervous system, whether general or local, are not infrequently 
associated with insanity, either as its cause, or as the concurrent conse- 
quence of some obscure morbid state. Insanity often complicates epi- 
lepsy; persons who are insane are apt to become epileptic; epilepsy not 
infrequently terminates in mental derangement, and more especially in 
dementia, and further acute maniacal attacks are liable to be associated 
with or to replace the epileptic seizure. In connection with hysteria, again, 
not only is a peculiar mental condition closely allied to insanity often 
present, but hysterical patients are liable to attacks of acute mania, and of 
chronic forms of mania and melancholia. Further, chronic diseases of the 
brain or cord are not infrequently attended, sooner or later, by insanity, 
and more especially by chronic mania or dementia ; among which may be 
included syphilitic and other cerebral tumors, sclerosis of the nervous 
centres, and the sequelae of apoplectic effusions, and of injuries to the skull. 
Many cases also are recorded in which insanity appears to have been in- 
duced by disease, or injury of nerves, and even by powerful impressions 
on the organs of special sense. Other local conditions liable to cause 
insanity, are those connected with the female reproductive organs : the 
most interesting and important of which are related to the puerperal state. 
It is somewhat rare for insanity to come on during pregnancy; on the other 
hand, insanity sometimes disappears on the supervention of this state. It is 
mainly in connection with parturition that insanity arises. Sometimes 
there is an acute outbreak of short duration during the very act ; some- 
times it occurs during the first fortnight after confinement, and is then 
generally attributed to some inflammatory or septicemic complication ; 
sometimes it supervenes at a somewhat later period, independently of any 
local or other disease that can be detected, and under such circumstances 
is apt to be chronic, though for the most part curable, and in the form 
of melancholia, or mania, not infrequently associated with nymphomania. 
Outbreaks of insanity occasionally attend the menstrual flow, and are 
sometimes induced by the suppression of that discharge. Many other 
affections besides those which have been discussed, are liable to be com- 
plicated by, or to cause, insanity ; amongst which may be enumerated 
diseases of the heart and lungs, diseases of the abdominal organs and kid- 
neys, tuberculosis, gout, chronic anaemia, and suppressed discharges of 
various kinds. But the most interesting in this respect probably are acute, 
and especially the acute febrile, diseases. Patients in these cases are some- 
times attacked with sudden and furious maniacal excitement, which may 
last for a few hours, or a few days only ; but not infrequently the attacks 
w r hich are then either melancholic or maniacal, become chronic, and 
although generally curable, may need to be treated in an asylum. These 
outbreaks occur for the most part during the subsidence of the disease, or 
even during convalescence. They are observed mainly in pneumonia and 
rheumatism, in enteric and typhus fevers, and in some of the exanthemata. 
They occur, too, in ague, in which case paroxysms of temporary insanity 
are apt to replace the ordinary febrile paroxysms. Acute anaemia, such 
as results from sudden and copious losses of blood, is sometimes attended 
with an outbreak of acute mania. 



INS ANT TY. 



1013 



Symptoms and progress In order rightly to understand the pathology 

of the brain, as that of all other organs, the necessity has long been recog- 
nized of regarding the morbid structures as mere modifications of the 
healthy structures, and to seek in the normal development of the healthy 
parts the clue to the abnormal development of the parts which are diseased. 
So, if we would rightly apprehend the pathology of the mind, as that of 
functional disturbance of other organs besides the brain, we must accept 
the facts that its abnormal actions are simply modifications of its healthy 
actions, and that the secret of their evolution is to be learnt from a care- 
ful study and comparison with them of the natural phenomena of the 
mind. 

The mind from the moment of birth, at which time it is a blank page, 
is constantly, through the instrumentality of the organs of sense, receiving 
impressions which paint themselves more or less vividly upon it. The 
impressions or perceptions which are thus made are stored up and remain 
henceforth the property of the mind, to be utilized by it, to be recalled 
from time to time voluntarily or involuntarily, to be analyzed, compared, 
combined, rearranged, and so to contribute to the formation of new and 
complex ideas — of a subjective world which reflects but idealizes the world 
without. Intimately associated with the perceptions and ideas which thus 
throng the mind are the mental qualities which give them their tone or 
color, and the purely intellectual functions by whose cold light they are 
examined. By the former are meant the senses of pleasure and of pain, 
the moods, the feelings, the passions, the moral qualities, which accompany 
them or which they call forth, and which pervade and leaven them, or 
put them in special aspects, or endow them with qualities which are not 
inherent in them, but are the reflexes of the mental conditions whence 
they are derived. The purely intellectual functions comprise memory, 
reason, and imagination, the powers by which we recall the perceptions 
and ideas which are stored up in the mind, by which we analyze, com- 
pare, and form judgments, and by which we rearrange our ideas, invent, 
and create. The springs of action have their sources in the functions 
which have here been considered. Impressions received in the perceptive 
centres, and even revived impressions, induce involuntary reflex actions 
for protective and other purposes. Under the influence of the various 
moods and passions not only do the features and the general demeanor re- 
veal with more or less accuracy the dominant emotional condition, but their 
subject is not infrequently driven to perform acts, it may be of heroism, 
it may be of crime, to which reason alone would never have prompted 
him, or from which it would have restrained him. Above all, presiding 
over all, is the will, at any rate that higher element of the will, by the 
exercise of which we give attention to and regulate our mental operations, 
and which governs, directs, and restrains the more or less wayward and 
uncertain impulses to action which originate in ordinary reflex conditions 
or in emotional disturbance. It need scarcely be added that the due 
relation of the mind to the external world requires, on the one hand, that 
the organs of sense shall be efficient and in uninterrupted connection with 
the perceptive centres, and, on the other hand, that the motor cell-groups 
for co-ordinated actions, together with the subordinate motor apparatus, 
shall have their normal .relations with the supreme centres of action. 

In mental disease, or insanity, there is necessarily disturbance of one or 
more of the fifnctions which have here been enumerated ; and consequently 



1014 



DISEASES OF THE NERVOUS SYSTEM. 



J 



we have to consider as factors of insanity, i disorders of sensation,' ' intellec- 
tual disorders,' and ' disorders of movement.' 

(a) Disorders of sensation The sense of illness, or of well-being, 

when illness is present, may be referred to this head. It is remarkable 
that in most cases of insanity the patient is quite free from any feeling of 
bodily ill-health, and on this account will often protest against medical 
treatment. There are other cases, however, especially cases of hypochon- 
driasis, in which the sense of illness is not only present, but profoundly 
exaggerated, and generally when convalescence is in progress the patient 
suffers from depression, fatigue, and other symptoms, which satisfy him 
that he is an invalid. Anaesthesia and analgesia are often observed, espe- 
cially in cases of melancholia and dementia; and these conditions may be 
general or limited to certain parts. But, in the larger number of cases, 
sensation remains unaltered, or there may even be hyperesthesia. The 
most interesting sensory disorders, however, are those which are known 
as illusions and hallucinations — the former term signifying the false per- 
ception of impressions which are made upon the organs of sense, the 
latter term signifying subjective sensory perceptions which ' are projected 
outwards, and thereby become, apparently, objects and realities.' It is 
clear that there is a real difference between hallucinations and illusions, 
and yet it is often difficult or impossible to distinguish between them. 
Thus, in delirium tremens, when the attendants, articles of furniture, and 
even shadows, are taken for devils or wild beasts, or muscce" volitantes, due 
to disturbance of the retinal circulation, are transformed into beetles, 
butterflies, or gold and silver coins, the patient is the victim of illusions ; 
but when he perceives similar things when nothing in the world around or 
in his organs of sense furnishes, so to speak, his mind with an excuse for 
seeing them, he suffers from hallucinations. Both illusions and hallucina- 
tions may involve any or all of the senses. In the following paragraph, 
we shall speak of them as if they were identical. Hallucinations of sight 
are probably more common than those of any of the other senses. 

They are seen, in different cases, by night, by twilight, or by day ; they 
may be vivid or shadowy; they maybe of short duration or persistent, or 
may come and go ; and they necessarily vary in character, in some cases 
animals, in some human beings, in some friends long dead, in some devils, 
in some angels, and in some panoramas crowded with life rise before the 
patient ; and they are shocking, terrifying, or agreeable, according to the cir- 
cumstances. Hallucinations of hearing are rather less common, and on the 
whole of graver augury than those of sight. They are especially common 
in melancholia and chronic mania. The patient generally hears voices, to 
which he listens, with which he converses, which he quarrels with or obeys. 
These voices sometimes appear to talk nonsense, frequently they upbraid or 
insult, or utter profane or obscene language, or revile the sufferer's friends 
or relations, or tempt or command him to do evil actions. They seem often 
as distinct as the real voices which are uttered around him, sometimes to 
come from articles of furniture or particular spots, sometimes to reach 
him from a far distance, and sometimes to be internal voices or voices 
without sound. Occasionally the patient hears discordant inarticulate 
noises, or strains of music. Hallucinations of smell, taste, and com- 
mon sensation, are not infrequent. As regards smell and taste, the 
impressions on the perceptive centres are almost always of a disagreeable 
or offensive kind. Illusions or hallucinations of common seifsation lead to 
the impression that animals are crawling over the skin, or that galvanism 



INSANITY. 



1015 



is being applied, or that frogs, snakes, birds, or the arch-fiend himself is 
present in the chest, abdomen, or head. They are especially common in 
relation to the reproductive organs in both sexes. Hallucinations and illu- 
sions of several senses are often present at the same time ; and when thus 
associated, they naturally tend to confirm to the patient the objective reality 
of his false impressions. 

It is important to observe that although illusions and hallucinations are 
amongst the most striking and important indications of insanity, their pres- 
ence by no means necessarily implies the insanity of the sufferer. Many 
cases have been recorded (and such cases are not uncommon) in which 
persons, in all other respects mentally sound, have seen casually, or have 
been troubled more or less persistently with hallucinations of sight and 
even of hearing, but who have been able by reason and observation to 
satisfy themselves of the unreality of their abnormal sensory impressions. 
Nor even does it necessarily follow that, because a patient believes in the 
reality of the phantoms which present themselves to his senses, he is to be 
regarded as insane. The natural credulity of many persons, the belief in 
which many have been brought up in the existence of ghosts, in the possi- 
bility of the reappearance of the dead, and in the naturalness of super- 
natural occurrences, and the inaptitude of most persons for scientific inves- 
tigation, make them ready believers in the objective reality of the phantasms 
which arise in their perceptive centres, especially if, as is most probable, 
the hallucinations have some obvious relation to the prevailing sentiments 
or beliefs. 

(b) Intellectual disorders — These comprise perversions of feeling, or 
of the affective functions, derangement of the intellect or of the ideational 
functions, and disturbances of the will, (a) Esquirol declares ' moral 
alienation to be the proper characteristic of mental derangement ;' and 
says, ' there are madmen in whom it is difficult to find any trace of hallu- 
cination, but there are none in whom the passions and moral affections are 
not perverted and destroyed. I have in this particular met with no ex- 
ceptions." The accuracy of the opinions here expressed is generally ad- 
mitted. The earliest indication of insanity in the great majority of cases 
is, not the occurrence of hallucination or perversions of the reasoning pow- 
ers, but some change in the patient's feelings, a sense of sadness, per- 
plexity, restlessness, dissatisfaction, or irritability, a feeling of buoyancy, 
extravagant joy, or recklessness, a condition of dulness, apathy or utter 
indifference, which pervades the patient's thoughts, which modifies his re- 
lations to the world about him, and more especially perhaps to particular 
objects, and which reveals itself more or less obviously in all his actions. 
The phenomena here referred to are not such as would necessarily strike 
the casual observer ; for among the many varieties of character presented 
by those among whom we dwell we undoubtedly not infrequently meet with 
some which differ little if at all in their actual condition from the abnormal 
characters of insane persons. The main indications (apart from the super- 
vention of other and more striking evidences of insanity) that such moral 
conditions as have been adverted to are insane, are partly their extravagance, 
but especially the fact of their coming on in persons in whom an opposite 
or at any rate different character had formerly prevailed. Thus, it is not 
the fact of a man being in a desponding frame of mind, neglecting his 
affairs, and attempting suicide, or of his being a liar, a thief, or shamelessly 
indecent, or of his being quarrelsome and revengeful, and attacking with 
fury those who thwart him, or of his being reckless in his speculations. 



1016 



DISEASES OF THE NERVOUS SYSTEM. 



and outrageously extravagant in his expenditures, which constitutes him 
insane, for such peculiarities of temper or of conduct are not uncommon 
in a greater or less degree among such as are altogether free from mental 
disease, and some at any rate may be developed temporarily with circum- 
stances which are ample to explain their presence ; but it is the fact that 
without adequate cause the man of a hopeful disposition becomes despond- 
ent and miserable ; the truthful, honest, and pure-minded Christian gives 
himself up to vicious practices ; the amiable and considerate friend be- 
comes quarrelsome and violent in his conduct, and the cautious and shrewd 
man of business loses his caution and shrewdness, and enters upon a course 
of wasteful expenditures and wild speculations. It is under the influence 
of such moral perversion that, without necessary delusion or obvious im- 
pairment of judgment, hatred, suspicion, jealousy, ungovernable rage, and 
other passions arise, often directed against their nearest and dearest rela- 
tions and friends, which drive their subjects to commit acts of violence 
and even murder ; and similarly under its influence that many persons are 
impelled to theft, arson, drunkenness, and various other extravagant follies 
or crimes, (b) Derangements of the intellect. The intellectual functions 
are probably always to a greater or less extent impaired or perverted in 
insanity. Generally the memory suffers. But in many cases, as for ex- 
ample in monomania, it appears to be, or is, unimpaired. And it is an 
interesting fact that, although occasionally no doubt patients on recovery 
from an attack of insanity forget in some degree or even absolutely all 
that occurred to them during their illness, they do in the large majority of 
cases retain a very fair recollection of their experience, and are slow to 
forget injuries or kindnesses which they have received at that time. Again, 
lunatics not infrequently have a vivid recollection of the events of their 
former lives, while forgetting (perhaps for want of attention) circumstances 
which have recently occurred ; and, on the other hand, former occurrences 
are sometimes blotted out, or become so hazy as hardly to be recognized 
as belonging to their experience. These peculiarities attach especially to 
chronic mania and dementia. In a large number of cases, however, it is 
not so much that accumulated knowledge is effaced from the mind, as that 
there is a loss of the power of voluntarily recalling it, and that it is apt to 
come up casually and unexpectedly — occasionally the memory appears to 
be preternaturally active. The faculty of ideation becomes affected, and 
for the most part largely affected during the progress of insanity. In some 
instances, as in melancholia, conceptions are slowly formed, and ideas pre- 
sent themselves sluggishly to the mind ; in other cases, as for example, in 
acute mania, they are developed tumultuously, and succeed one another 
rapidly, and the mind is kept in a constant whirl. The prevailing char- 
acter of the patient's ideas is largely determined by his prevailing mood, or 
temper or passion ; and hence in melancholia his ideas are for the most part 
gloomy and desponding ; in mania, vivacious, humorous, grotesque. Further, 
there is often an obvious connection between the prevailing insane ideas, 
and any vivid impression that happened to be made on the mind immedi- 
ately before the attack. When the ideas are sluggish, as they are apt to 
be in dementia and melancholia, they are often persistent, or tend to recur. 
This persistency of certain ideas or certain groups of ideas is especially char- 
acteristic of monomania. When, on the other hand, the ideas flow rapidly, 
they are less tenacious, and although still largely determined by the pa- 
tient's emotional state, are largely called up by the persons, things, and 
occurrences about him, and by whatever attracts his attention for the 



INSANITY. 



1017 



moment. Under these conditions, too, they are liable to follow one an- 
other without mutual connection, and to become incoherent. Incoherence, 
however, depends not only upon tumultuousness of ideas, but upon failure 
of ideas and general loss of mental power. It is not necessarily paucity 
of ideas, or superabundance, or incoherence, or inappropriateness, or 
oddity, or fixity of them that constitutes insanity ; for many sane persons 
are characterized mentally by some one or more of these conditions, and all 
of us are liable to incoherence of thought and inappropriateness. But 
here, as in affective insanity, the answer to the question as to whether a 
patient is insane or not must depend largely on a comparison between 
his present mental condition and that which characterized him formerly. 
And especially much will depend on the point of view from which the pa- 
tient regards his ideas, and on the influence which they exert over his con- 
duct. The reasoning powers are doubtless impaired in all cases of insanity. 
This is not always at first sight apparent ; for many lunatics, especially 
monomaniacs, argue with considerable skill, not only on general matters, 
but even on the subject of their delusions, for their belief in which they 
sometimes adduce the most plausible reasons ; and others, as for example, 
persons suffering from acute mania, converse with no little brilliancy, 
making sparkling and witty observations, and being ready with repartee 
and sarcasm. In the former case, however, close observation will proba- 
bly reveal manifest mental weakness, and especially an inability to appre- 
ciate or to meet arguments directed against their delusions. And in the 
latter case the readiness of retort, and the vivacity of speech are associated 
with a total loss of power to pursue any train of reasoning, or even to sus- 
tain a connected conversation. But the failure of the reasoning powers 
becomes specially apparent when illusions, hallucinations, and vivid ideas 
take possession of the mind, and are accepted as objective realities or 
fundamental truths, and form at once the substratum and the motive of the 
patient's thoughts and actions — when in fact they become delusions and the 
foundation probably of a superstructure of further delusion. Delusions 
are often of slow growth, and though constituting perhaps the most strik- 
ing phenomena of insanity, for the most part appear secondarily either to 
the moral disturbance which is generally the earliest symptoms of mental 
disease, or to that phase of insanity which. is characterized by hallucina- 
tions, and by undue slowness or rapidity, or perversion of ideas. The 
melancholic patient presents in the first instance a sense of profound 
depression ; and it is only subsequently that a definite delusion crystallizes 
as it were out of this general feeling, and becomes the assigned cause of 
his mental condition. The patient whose affective state is at first one of 
gayety and restlessness, only at a later period acquires the expansive delu- 
sion that he is enormously rich, as strong as Hercules, a king of men, or 
the Almighty. And often, as we have shown, illusions and hallucinations, 
and it may be added insane ideas, are recognized for a time by the patient 
at their proper value, and are resisted and wrestled with by him, until 
probably at length his reason yields at discretion, and becomes their cap- 
tive. It is of course mainly in dementia that the reasoning, as well as 
other mental attributes, fails, (c) The varied impulses to action which 
operate in health are all liable to affection in mental disease. The strong 
man becomes vacillating, the weak and timid grows obstinate and resolute. 
It is indeed curious to observe how, in some cases, the patient seems to 
lose all power of will, how he apparently loses all capacity not only for 
directing his thoughts, but to decide for himself whether or not he shall per- 



1018 



DISEASES OF THE NERVOUS SYSTEM. 



form even the most trivial action ; while, in others, he seems impelled by 
a stubborn and unbending determination to perform some malicious or 
wicked act, or to cany out some absurd design. Careful examination and 
inquiry will probably show in all cases that there is a more or less mani- 
fest failure of that higher element of the will, in virtue of which we fix 
attention upon ideas and trains of thought, compare, analyze, and force 
them into due relation, and by means of which we control and direct the 
various impulses to action determined by our perceptions and ideas, and by 
the moods and passions which alternately sway the mind. It is largely 
owing to the power of these conditions that the victim of hallucinations of 
the senses ends by accepting the hallucinations as facts, or that so-called 
'insane' ideas become fundamental beliefs. And it is due in great meas- 
ure to the second of these conditions, that the patient yielding to the un- 
controlled impulses of the moment performs acts which in a healthy frame 
of mind his reason would have restrained him from. It often happens, 
that compelled by impulses, against which haply they may have striven 
with all their might, patients, not apparently otherwise insane, commit 
thefts^ perform indecent acts in public, set fire to hay-stacks or houses, 
give themselves up to bouts of drinking, attempt suicide, or make murder- 
ous assaults. At the same time it is important to recollect that apparently 
impulsive insane actions are not necessarily or even principally due to in- 
stinctive or moral causes. In a large number of cases, and in many in- 
stances too where it is wholly unsuspected, the patient acts under the influ- 
ence of some delusion : he is ordered by some peremptory voice, or by the 
Almighty himself, to help himself to some one else's property, to kill his 
children or his wife, or to destroy himself ; he makes murderous attacks 
either to defend himself from those whom he supposes to be working him 
mischief, or to destroy the arch fiend whom he believes to be present in 
human guise, or to save his friends from impending peril ; he puts his hand 
in the fire and reduces it to a cinder, in the belief that fire has no influence 
over him ; he refuses food, because he belongs to the immortals, and does 
not need it, or because he imagines that it is poisoned ; he remains motion- 
less for fear that being made of glass he shall be broken in pieces, or be- 
cause a false step or even a change of position shall cast him into the bot- 
tomless pit which is yawning at his feet. 

(c) Disorders of movement In the remarks just made the performance 

of combined actions in obedience to the dictates of emotional impulses or 
of the will were alone under consideration. Under the present heading it 
is intended simply to call attention to the modes in which muscular actions 
are executed in madness — to the defects or modifications of movements 
which may be present. It is probably rare to observe entire healthiness 
of action in those who are insane. In most cases the expression of the 
features or the movements of the body, reveal to the practised eye the 
patient's mental condition. The wandering look of one, the sullen or 
suspicious aspect of another, the self-satisfied air of a third, are severally in 
full accordance with the prevailing emotional condition ; and a similar 
conformity may be observed between the restlessness of movement, the in- 
ertness of manner, the obstinate immobility, which are frequently met with, 
and the patient's state of mind. But other muscular phenomena besides 
these are generally present. In some cases the muscles are rigid, in some 
relaxed. In some there is apparently excess (temporary, no doubt) of 
muscular strength, in more there is actual loss of power. Occasionally a 
condition of catalepsy is present, and often more or less distinct paralysis 



INSANITY. 



1019 



is observed. As regards the special phenomena of ' general paralysis of 
the insane,' we shall reserve our observations until we come to the consid- 

I eration of that disease. Further, local paralyses and spasms, such as occur 
under other circumstances, are not uncommon here ; among these may be 
included hemiplegia, paralysis of* certain nerves connected with the head 
and neck and face, epileptic convulsions, convulsive movements of particu- 

I lar parts, chorea-like affections, rhythmical actions, difficulties of articula- 

| tion, and nystagmus. 

It need scarcely, perhaps, be added that in most if not in all cases of in- 
sanity, the several disorders which have just been discussed separately, 
and may exist alone, become combined in a greater or less degree, and 
concur in the development of the special insane mental phenomena which 
each patient presents ; and that they act and react on one another in such 
a way that it becomes extremely difficult and often absolutely impossible 
to estimate their several influences upon the patient's thoughts and actions. 
This difficulty is especially great in the case of dementia, where the per- 
verted mental powers have undergone gradual deterioration, and the mo- 
tives to action are mainly the satisfaction of the appetites, and the mere 
shreds of moral and intellectual attributes which survive the general men- 
tal wreck. 

The remarkable resemblances which exist between dreaming and states 
of somnambulism artificially induced, on the one hand and insanity on the 
other, have long been observed. In dreaming our mental faculties are 
only partly annulled by sleep. Some are still wakeful, but wakeful in 
different degrees ; and between these all sense of proportion is lost. Sub- 
ordinate mental phenomena fitfully or not at all controlled by the higher 
intellectual powers attain unwonted importance. Ideas and hallucinations, 
ever varying and with little interconnection, but determined to some ex- 
tent by sensory impressions, and by the thoughts and occupations which 
preceded sleep crowd the mind, and are accepted by it as realities. There 
is a total loss of knowledge of our actual relations with the external world, 
and even of our relations to time and space. Memory fails to recall in 
orderly sequence the events of our past lives, even those which have just 
occurred ; but it brings together confusedly fragments of our previous ex- 
periences, sometimes fragments which had seemed to be utterly forgotten, 
and blends them into contemporaneous pictures. It even invents recollec- 
tions, and passing thoughts are taken for personal reminiscences of what 
never occurred to us. The reasoning faculties specially fail. There is 
little or no power of comparing or analyzing the pictures or ideas which 
present themselves to the mind ; however absurd, however outrageous, 
however impossible they would appear to us if awake, they are accepted 
as a rule without question and as a matter of course by our sleeping senses ; 
and even though at times we appear to ourselves to reason with acuteness 
and to argue with vehemence and triumphantly, it is well known that almost 
always, if on waking our arguments can be recalled to mind, they are 
found to be disconnected, shallow, and even nonsensical. The moral 
feelings are also involved in sleep. The sentiments of joy, vanity, pride, 
and generally of exaltation are by no means infrequently excited, and, on 
the other hand, cunning, hypocrisy, remorse, ungovernable fury, coward- 
ice, and horror are common mental phases of the sleeping state. Further, 
it may be remarked that at any rate some forms of insanity have a resem- 
blance to dreaming, in the facts of the abeyance of the external senses and 



1020 



DISEASES OF THE NERVOUS SYSTEM. 



of their moral influence over the mind, and of the more or less complete 
severance between the mental phenomena and the responsive action of the 
muscles. In connection with this subject it is interesting to consider that 
it is not uncommon for insane patients during convalescence or after re- 
covery to speak of their past mental condition as though it had been a 
dream ; that these outbreaks of temporary impulsive insanity which some- 
times precede, sometimes replace an attack of epilepsy, and which often 
impel the patient to deeds of purposeless violence, are apt to pass abso- 
lutely from the memory, as a dream often does ; and further, that if the 
dreamer were during his sleep to act in accordance with his delusions and 
impulses, as in his dream he believes he does, — if the honest man were to 
pilfer, the virtuous man to commit a rape, the loving father to disembowel 
his child and put it in the dust-bin, if he were to hold conversations with 
his interlocutors, and generally to play his part in the fantastic and unreal 
world in which he seems to live, — there would be little to distinguish be- 
tween the condition of the sleeper and that of the lunatic, except perhaps 
that the lunatic is more or less alive to all that is going on round about 
him, and that the facts of the external world and his relations to them 
(it may be falsely seen and falsely interpreted) are mingled with his insane 
moods, his insane ideas, and his other insane subjective phenomena. 

There are two fundamental divisions of insanity ; the one characterized 
by perversion or disease of the emotions or passions, the other characterized 
by perversion or disease of the reasoning powers. The former is termed 
affective insanity, the latter ideational or intellectual insanity. It is not 
pretended that all lunatics can be placed in one or other of these categories, 
or indeed that affective insanity and ideational insanity often exist inde- 
pendently of one another ; but it is a fact that in the great majority of 
cases insanity commences with some change in the feelings, some perver- 
sion of the moral qualities, some affection of the passions which stamps 
itself on the features and demeanor, and influences the conduct, and that 
it is only subsequently that delusions and other evidences of intellectual dis- 
ease manifest themselves. It is a fact too that the patient may never pass 
beyond the stage of affective insanity ; and it may be added that moral 
perversion persists as perhaps the most important factor in the constitu- 
tion of all cases even of ideational insanity. 

Again, it is now generally acknowledged, as Guislain was the first to 
establish, that in by far the larger number of cases the earliest indications 
of insanity consist in a ' state of profound emotional perversion of a de- 
pressing and sorrowful character,' and that it is only at a later stage, if 
at all, that morbid feelings and passions of exaltation show themselves. 

Although admitting the undoubted truth of the principles just enun- 
ciated, we shall not attempt, any more than other authors have done, to 
classify the varieties of insanity according to one or other of them ; and 
while acknowledging most thoroughly that different forms of insanity pass 
into one another, and that many cases are met with which can only with 
a certain amount of violence be assigned to any particular division, we 
shall adopt, in the main, the system of classification which has been ac- 
cepted — at any rate in principle — by most writers on the subject. Accord- 
ingly we shall arrange mental diseases under the following six heads : — 

1. Melancholia, characterized by mental depression ; 
,2. Mania, characterized by mental exaltation ; 

3. Monomania, or partial madness, generally attended with exaltation; 



INSANITY. 



1021 



4. Dementia, characterized especially by mental weakness; 

5. General paralysis of the insane ; 

6. Idiocy, or congenital mental weakness. 

1. Melancholia The specific character, the fundamental phenomenon 

of melancholia, is the presence of a profound sense of painful depression — 
a feeling of oppression, anxiety, dejection and gloom. This condition, 
indeed, as has already been stated, constitutes the early stage of most cases 
of insanity. It may come on without obvious cause, or it may supervene 
on some bodily illness, or on some mental perturbation or shock. For the 
most part its onset is gradual ; the patient feels unhappy, irritable, annoyed 
with himself and all about him ; he loses interest in what formerly gave 
him pleasure ; everything is a trouble or misery to him. The world is 
physically unchanged, and yet an altered relation between himself and the 
world has arisen which he cannot understand, and for which he cannot 
yet assign a cause. At first he most likely endeavors to conceal the 
wretchedness he feels ; but soon probably he either mopes, withdraws 
himself from observation, and neglects his business and his duties, or he 
gives vent to his feelings in irritability of manner, quarrelsomeness, and 
perhaps displays malice or hatred towards those who should be, and were, 
dearest to him. The malady may not proceed beyond this point ; but in 
most cases hallucinations and delusions manifest themselves after a time — 
hallucinations and delusions which correspond closely in character with 
the patient's affective state. It was formerly believed, and is even now 
not infrequently supposed, that the delusions of melancholia are the cause 
of the mental gloom and misery ; but that is not the case. On the con- 
trary, the special delusion or delusions which the patient manifests, crys- 
tallizes, so to speak, out of his large and vague feeling of depression. 
Seeking, it may be, for some explanation of his altered state, which 
probably no one, up to this time, appreciates and deplores more than he 
does himself, his mind dwells upon some special subject (determined, prob- 
ably, by his former pursuits or inclinations, or by accidental circumstances), 
until at length it assumes a predominant influence over him, and becomes 
transformed into a delusion. This apparent revelation to him of the cause 
of his mental change is oddly enough not infrequently attended with some 
diminution of his despondency ; and oddly, too — a circumstance tending 
to show that the delusion is not the real cause of his condition — the dis- 
covered cause is often altogether trivial, and quite inadequate to explain 
the consequences supposed to flow from it, just as the intense horror or 
dread which attends nightmare is for the most part altogether dispropor- 
tionate to the imaginary incidents which seem to cause it. The delusions 
of melancholia are of the most various kind. In a large number of cases 
the patient believes that he has committed some unpardonable crime, that 
he has done murder either in deed Or thought, that he is a thief, that he 
has been unchaste, that he has committed the unpardonable sin, that he is 
a disgrace to his family and to humanity, that he is forsaken of God, and 
doomed to eternal punishment. In other cases he harbors the delusion 
that some kind of possession or transformation has taken place in him ; 
he is possessed by the devil, or by a legion of devils, or he has been trans- 
formed into the evil one; he has become a dog, a wolf, or a toad; he is 
made of glass ; he is a mass of corruption ; he exhales offensive odors, 
which render him an object of disgust ; he is a corpse, or his former self 
is dead, and that which passes for him is something or some one else. 
Or his delusions have special reference to other persons ; he is an object of 



1022 



DISEASES OF THE NERVOUS SYSTEM. 



general suspicion ; everyone is making remarks about him, or pointing 
him out ; detectives are on the lookout for him ; spies are constantly dog- 
ging his footsteps; his friends are untrue, or his wife unfaithful; or dread- 
ful calamities are threatening those who are dearest to him — calamities for 
which, probably, he is in some way or other answerable, but which he 
cannot prevent. Or, again, he regards himself as the victim of some per- 
son, some power, or some conspiracy ; he is being poisoned ; he is sub- 
jected to the influence of electricity ; his thoughts and actions are directed 
in some marvellous way by some one who owes him a grudge, or has 
acquired undue influence over him ; or he is bewitched. It is almost 
needless to say that hallucinations and illusions are usually associated with 
the patient's delusions, and these form an integral part of them. There is 
little doubt that the belief so common among melancholies, that they are 
being subjected to galvanism, is determined mainly by hallucinations or 
illusions of common sensation, and that the notion of being made of glass, 
of being slowly burnt, of being one of the lower animals, of harboring inside 
them unholy or loathsome beings, is equally connected with some perver- 
sion of the cutaneous or visceral sensibility. The delusion that he is a 
corpse, that he is being poisoned, that he exhales a disgusting odor, may 
sometimes be referred to affections of the patient's sense of taste or smell. 
It is in this case especially that the sufferer hears voices which whisper 
abominable words or sentiments, which revile and upbraid him, which utter 
calumnies against his friends, which tell him that he is damned, which in- 
cite him to acts of violence or crime. Hallucinations of sight also are 
common; the patient sees the enemies or fiends that are pursuing him, the 
judge and jury before whom he is being tried, portents in the heavens, 
death and destruction around him, hell yawning at his feet. 

The aspect and demeanor of melancholic patients, though very various, 
are in accordance with their mental condition. The expression is, accord- 
ing to circumstances, irresolute, sad, suspicious, moody, or concentrated; 
the eyes cast down, or fixed with an intense look of pain or horror. 
Generally the patient's movements are languid and feeble, and he remains, 
perhaps, all day long in one place, and even in one position. Sometimes, 
under these circumstances, his limbs become rigid, and his muscles may 
even assume a cataleptic condition ; sometimes, on the other hand, they 
are fiaccid. In many cases the patient is restless, constantly moving about, 
perhaps hovering around the keeper or the doctor from whom, may be, he 
vaguely hopes to obtain relief from his sufferings ; or he takes long walks, 
and not infrequently bursts out crying, and wrings his hands in an agony 
of grief. 

Sensibility is often affected in melancholia. There may be more or less 
general anaesthesia, or there may be uneasy sensations referred to the limbs 
or trunk, to the skin, or the internal organs. Especially, perhaps, the 
patient suffers from abnormal feelings in the head and spine, and from a 
diminution of sexual desire. 

The sleep of melancholies is generally disturbed. For the most part they 
sleep little, they are troubled with painful dreams, and they wake up unre- 
freshed. They are apt to believe erroneously that they do not sleep at all. 

The gastro-intestinal functions generally suffer. There is almost always 
constipation. The appetite often fails; but sometimes, on the other hand, 
it is almost insatiable. The refusal to take food, which is so common in 
melancholia, does not usually depend on loss of appetite, but for the most 
part arises from the fear of being poisoned, the wish to commit suicide, 



INSANITY. 



1023 



obedience to some command, or from some other delusion. Nutrition 
often suffers ; the patient emaciates, his skin becomes hard and dry, his 
face assumes a livid or cadaverous hue, which, with the attendant emacia- 
tion and modification of expression, imparts a premature aspect of age; 
his temperature becomes lowered, his pulse weak and often slow, and his 
extremities cold and livid. 

The course of melancholia is generally chronic. In some instances the 
patient presents remissions, and much more rarely complete intermissions 
or lucid intervals of short duration. If recovery takes place it is generally 
gradual, and within six or twelve months from the time of seizure. If the 
symptoms extend beyond this limit, recovery is almost hopeless. Melan- 
cholia of low intensity may continue with little change for many years. 
It has already been pointed out that a melancholic stage precedes most 
maniacal outbreaks. In these cases the actual melancholia is of short 
duration. Again, cases are not infrequently met with (folie circulaire of 
Falret) in which insanity pursues throughout a succession of alternate 
stages of melancholia and mania. Melancholia may leave behind more or less 
marked traces of mental weakness, and may even end in dementia. It has 
been estimated that somewhat more than half the cases of melancholia get 
well ultimately, although of these a large proportion are liable to relapse ; 
and that of the remainder, some continue with little change of symptoms, 
others pass into mental weakness or dementia, and others die. Death may 
be due to self-inflicted injuries, to starvation or its consequences, to phthisis 
or other tubercular affections which are extremely common in this form of 
insanity, and lastly to pneumonia, or other intercurrent visceral affections. 
It has been observed that diseases, more especially, perhaps, acute dis- 
eases, occurring in the course of melancholia, are apt to have an important 
influence over it ; sometimes they ameliorate, or even cure the mental 
malady ; but in other cases, and probably quite as often, they aggravate it. 

The above account of melancholia is general, and applies more or less 
accurately to the greater number of cases that come under observation. 
But there are many groups of cases which present special characteristics, 
and require, therefore, some separate consideration. 

(a) Hypochondriasis is often not regarded as a form of insanity ; but as 
Griesinger observes it is properly a ' folie raisonnante mUancholiqae^ a 
form of melancholia in which there is mental depression, without necessary 
delusion or impairment of the reasoning powers, especially characterized 
by a sense of profound illness, and a tendency to exaggerate such feelings, 
and to brood over them. Hypochondriacal patients for the most part, but 
not necessarily, suffer from uneasiness, pain, or actual illness ; and it is in 
connection with these mainly that their feelings of profound misery and 
gloomy foreboding arise. They dwell constantly on their real or supposed 
maladies ; they examine and discuss mentally every new phenomenon 
which presents itself; they are always looking at the tongue or feeling the 
pulse, and on the watch for new .symptoms ; on altogether insufficient 
grounds, probably, they not merely argue themselves into the belief that 
they have certain internal diseases which must prove fatal, or render their 
lives utterly miserable, but they invent outrageous explanations of obscure 
groups of symptoms, such as that they have toads or serpents inside, or 
that their food coagulates within them and forms a solid mould of the 
stomach and bowels, or that they are quite devoid of these important 
organs ; they consult medical works and apply to themselves the horrors 
of which they read ; and their conversation is for the most part devoted to 



1024 



DISEASES OF THE NERVOUS SYSTEM. 



a wearisome account of the sufferings of which they believe themselves to 
be the victims. They usually take little or no interest in other persons' 
affairs ; are selfish, querulous, and quarrelsome, weak, vacillating, and in- 
firm of purpose ; they have an air of sadness or misery, and neglect the 
duties which should devolve upon them. Not infrequently new maladies 
arise and replace the old ones, and they have a tendency to go from phy- 
sician to physician in search of the relief or cure which does not come. 
Occasionally actual insane delusions arise, chiefly in connection with their 
predominant feelings of illness, and the patient becomes insane beyond 
all question, and very commonly, although he appears to reason correctly 
on all other subjects, his mental powers appear to be clouded and weak in 
regard to the supposed cause of his malady. It is not often that hypo- 
chondriasis impels to homicide, or even to suicide. Hypochondriasis is 
especially frequent in young persons, and mainly in those of the male sex. 
As it is often associated with the presence of actual disease, it is always 
important to institute a careful examination of hypochondriacal patients. 
Recovery is not unusual with appropriate treatment. 

(b) Melancholia with stupor is a variety of melancholia which presents 
a superficial resemblance to dementia, was long confounded with it, and 
even now is sometimes difficult to distinguish from it. In this condition 
the patient's whole mind appears to be engrossed in one all-absorbing 
painful delusion ; and though his senses are open and convey to the sen- 
sorium all the impressions which they receive, his pre-occupied mind takes 
little or no cognizance of them, and his features and limbs remain alike 
motionless. The nature of the delusions from which the patient suffers 
differs of course in different cases ; sometimes there is simply a vague sense 
of impending calamity, sometimes he stands on the brink of an abyss, or 
hell itself yawns to receive him, sometimes he has committed some great 
crime and awaits the verdict of the jury and the sentence of the judge. 
His expression is fixed, and it might even be imagined that he was insen- 
sible ; but his face wears a look of intense horror, awe, grief, or anxiety. 
His limbs are motionless, occasionally flaccid, occasionally rigid or plastic, 
as in the cataleptic condition. He takes no notice of what is actually 
going on around about him ; he does not flinch from ordinary painful im- 
pressions, or from noises made close to his ears, or blows aimed at his 
eyes ; but probably his pupils contract to light, and if a jug-full of water 
be poured on him a sudden inspiration follows. He takes no food, or at 
any rate requires to be fed ; he passes his evacuations without notice, and 
if not confined to bed needs to be put to bed and taken out of bed, dressed 
and undressed like a patient in a late stage of dementia. Melancholia with 
stupor may last for a few hours only, or for several days, weeks or months. 
It sometimes comes on in the course of other forms of insanity, sometimes 
arises suddenly, especially after some sudden mental shock, or in connec- 
tion with epilepsy. Recovery from it is Often sudden ; and the patient is 
apt to express himself as if he had recovered from some frightful dream — 
indeed, there is a marked resemblance between this condition and nightmare. 

(c) Melancholia with destructive tendencies is often met with. These 
may be suicidal, homicidal, or directed against inanimate objects. More- 
over, they may arise in different ways. In some cases persons unaffected 
with hallucinations or delusions become the subjects of a more or less un- 
controllable impulse to destroy themselves, to kill infants entrusted to their 
care, or to steal, burn, or otherwise destroy ; and not only may they have 
such impulses, but they may recognize their heinousness fully, may mourn 



INSANITY. 



1025 



over their own condition, may strive, for a time at any rate, more or less 
successfully against them, and may even seek the restraint of a madhouse. 
In other cases, as for example in the course of epilepsy, patients are sud- 
denly urged by some blind ungovernable impulse, generally in connection 
with hallucinations or delusions, to commit the grossest outrages, to debauch, 
to mutilate, to murder, or, it may be, to destroy themselves. In other 
cases the impulse to suicide or murder is the almost necessary result of the 
long-continued mental misery from which the patient suffers ; under the 
influence of his profound depression, and perceiving no other possibility of 
escape he destroys his life, or takes (in order to spare them a miserable 
future, or to send them to a better world) the lives of those who are dearest 
to him. But very frequently the determining cause of the patient's action 
is some hallucination or delusion which dominates his mind ; he kills him- 
self or others because some voice which he dares not disobey tells him to 
do it, or he commits murder because he regards his victim as an enemy 
who ought to be destroyed. It is important to observe, however, that 
murder or suicide by the insane is not always due to any destructive desire 
or impulse ; but that occasionally, for example, a madman will kill him- 
self in the attempt to prove his immortality, or his child in the full belief 
that he is Christ, and will rise the third day. Among destructive impulses 
must be included those which impel patients to tear up their clothes and 
bedclothes, and especially that which incites to the setting fire to hay- 
stacks, houses, and the like. Although we have here drawn attention to 
what may be regarded as a special group of melancholic cases, it must be 
remembered that all melancholic patients, however inoffensive they may 
seem to be habitually, are liable in a greater or less degree to sudden im- 
pulses to kill or destroy. 

(d) Melancholia with excitement Again there are cases in which mel- 
ancholia puts on some of the trappings of mania. In these the bodily activity 
is much greater than it is in ordinary cases of melancholia ; the patient is 
excited, restless, rambles about, and wrings his hands, or performs other 
muscular movements ; but withal his frames of mind and his delusions are 
less variable than they usually are in mania, and present, as is character- 
istic of melancholia, a certain degree of monotony. 

2. Mania is characterized specially by sentimental exaltation, intellectual 
vivacity and incoherence, and excited muscular action. It may break out 
suddenly, or come on in the course of certain acute febrile and other dis- 
orders. But much more commonly its onset is insidious. In this case it 
is usually ushered in, as melancholia is, with depression ; and, indeed, the 
beginnings of both forms of insanity are in the main identical. After the 
period of depression has lasted a longer or shorter time, the patient's con- 
dition gradually changes ; he becomes restless, dissatisfied, wanders about, 
roams the streets or fields, or visits friends with the vain hope of obtaining 
relief from his distressing feelings ; and then by insensible gradations his 
depression and discomfort cease, he becomes lively, loquacious, and boister- 
ous, is readily excited to anger or laughter, is vivacious and varied in his 
thoughts and language, speaks in a loud tone, entertains an overweening 
opinion of his bodily and mental powers, and displays increased and in- 
cessant muscular activity. During the stage of mental depression he often 
feels ill, and complains of painful or distressing sensations referred to differ- 
ent parts ; but as the true maniacal condition supervenes such feelings sub- 
side, and he seems to himself to be in the best of health. 

The most remarkable feature of mania is the disturbance of the affective 
65 



1026 



DISEASES OF THE NERVOUS SYSTEM. 



functions which it presents, together with the impulse to incessant activity 
which accompanies this disturbance. The patient's mood is for the most 
part one of exaltation, and is not only different in different cases as re- 
gards both intensity and character, but is constantly varying in the same 
individual; and his actions are determined in great measure by the senti- 
ments of the moment. Sometimes he is sad, ill tempered, angry, suspi- 
cious, or ferocious ; more frequently, perhaps, he is gay, jovial, boisterous, 
or vain, proud, and arrogant ; or, again, he may be acquisitive, or lasciv- 
ious, or dominated by appetites of another kind. In accordance with these 
various moods or moral conditions, we observe some patients indulging in 
frivolous or harmless actions, such as dancing, singing, laughing, shout- 
ing; some cursing and swearing, using obscene language, tearing and de- 
stroying whatever comes in their way, and committing violent and unpro- 
voked assaults ; some collecting and accumulating all kinds of rubbish and 
filth, or freely displaying their lascivious feelings and even masturbating 
openly and shamelessly, or eating garbage and even fecal matter, or 
giving themselves to drink. It may be observed that some of these 
affective states, and the actions which result from them, are determined 
by bodily disorders, especially by conditions of the sexual organs ; that in 
most cases there is a tendency for the patient's moods to change frequently 
and suddenly ; and that not infrequently, at any rate in the earlier stages, 
he is apt to have some consciousness of his abnormal state, and will occa- 
sionally try to control or conceal it. 

The intellectual characteristic of mania is not so much the existence of 
hallucinations and delusions, though these are usually if not always pres- 
ent, as the incessant tumultuous flow of ideas. In its slightest form this 
amounts to little more than an increased vivacity of thought, accompanied 
probably by an exaltation of the memory, which manifests itself by un- 
usual brilliancy of conversation, readiness of retort or sarcasm, an aptitude 
to look at things in new lights, to see unsuspected resemblances, and hence 
to utter witty or humorous or poetical expressions and thoughts, a tend- 
ency to speak in rhyme, to discourse with unwonted fluency and eloquence, 
and to propound startling speculations and theories. In more advanced 
cases, or in severer forms of mania, this apparent intellectual elevation 
runs into incoherence ; ideas still more or less in accordance with the 
patient's affective condition, and still following one another rapidly, have 
now little or no connection with one another ; there may still be flashes of 
wit or sarcasm, still fragments of eloquence or of versification, still thoughts 
of exaltation, but they are determined largely by impressions made upon 
the senses, and pass from the patient's mind as soon as they are uttered or 
expressed. 

Illusions, hallucinations, and delusions are all common in mania, and 
their presence largely determines the character of the patient's thoughts, 
speech, and actions ; moreover, they themselves are in their origin inti- 
mately related to the feelings which are predominant in the mind. It is 
owing probably to illusions or hallucinations of the muscular sense that 
maniacs so often entertain the belief that they are endowed with super- 
human strength ; that they can run, or fly, or play at cricket, or perform 
other athletic exercises with marvellous skill. And it is due to a some- 
what similar cause that such patients sometimes write or recite incoherent 
nonsense which they regard as poems surpassing those of Homer or Shak- 
speare ; that they boast themselves to be mathematicians, or orators, or 
singers, such as the world has never before seen ; that they believe them- 



INSANITY. 



1027 



selves to be in communication or correspondence with statesmen and 
emperors ; that they regard themselves as the possessors of untold wealth, 
and even of the asylum in which they are incarcerated ; and that they 
hold themselves to be Wellington or Napoleon, the Queen, the brother of 
Christ, or Christ himself, or, it may be, all three persons of the Trinity 
at once. 

It is important, however, to observe that, in mania, the hallucinations 
and delusions which affect the patient are, like his ideas and moods, fleet- 
ing and various ; that individually they do not, as a rule, take any strong 
hold on the mind ; and that, in this respect, there is a marked contrast 
between mania and melancholia, and especially between mania and mono- 
mania. 

Sleep is generally impaired in insanity. It is often troubled, and, in 
many cases, absolute sleeplessness may be continued without intermission 
for weeks or even months. A good night's rest, though in itself a favor- 
able sign, often occurs without the slightest benefit to the mental condition 
of the patient. 

The movements of maniacs are, as a rule, incessant. It is often held 
that they are stronger than in health ; but this is for the most part incor- 
rect. Nevertheless it is remarkable how maniacal patients will sometimes 
without any intermission by day or night, and apparently without fatigue, 
continue for many weeks to execute violent muscular movements. Grind- 
ing of the teeth and convulsive actions of groups of muscles are not un- 
common ; and occasionally partial paralyses, especially ushering in general 
paralysis, supervene. 

Various sensory phenomena are apt to arise in the course of mania, 
such as headache, uneasiness at the chest, aches in the limbs, sensations 
of heat and cold, and the like. Anaesthesia, too, is sometimes observed. 
The appetite is often enormously increased ; and not infrequently there 
is a tendency to eat tilth of all kinds, and even excrement. In some cases 
the desire for food is wholly absent. Sexual feelings are generally in- 
creased, and more especially in females ; and reveal themselves by looks 
and gestures, obscene conversation and language, masturbation, and the 
like. The menses are generally irregular or absent. There is nothing 
special to observe about the circulation except that it is often weak, and 
the pulse somewhat quicker than natural. The face is apt to be con- 
gested, and the eyes bloodshot ; but, on the other hand, the hue of the 
skin is not infrequently sallow and even cyanotic. Notwithstanding the 
patient's probably enormous appetite, he usually becomes thin and wrinkled, 
and looks older than he is. The bowels are apt to be irregular, and espe- 
cially to be constipated. The temperature of the body is for the most part 
little if at all increased. Occasionally, however, it rises a little, sometimes 
in connection with bodily illness, and especially in those cases in which 
the patient has little sleep and passes into a typhoid state. 

The course of mania varies in different cases. Occasionally it is uni- 
formly progressive ; but much more commonly it is attended with alter- 
nate exacerbations and remissions — the latter being sometimes complete. 
Complete intermissions sometimes occur periodically ; exacerbations are 
likely to supervene at the menstrual periods ; and, in a large number of 
cases, the variations in the condition of the patient take place, so far as 
can be ascertained, without any obvious cause. We have already referred 
to the periodical alternations between mania and melancholia, to which con- 
dition the name of 'folie circulairtf has been given. Maniacal outbreaks 



1028 



DISEASES OF THE NERVOUS SYSTEM. 



may vary in duration between a few hours and several months ; but, in 
most cases, and generally when the attacks are of long standing, they are 
attended with remissions, and may thus be continued for many years. 
Eecovery from mania is sometimes sudden ; but more commonly it takes 
place gradually. Occasionally its cessation is connected with the super- 
vention of some bodily disease, such as diarrhoea or fever. Recovery 
generally takes place, if at all, within a year ; but it may be delayed until 
the second year. After this, recovery is very rare, yet cases are occasionally 
met with in which it has been delayed until after the sixth or seventh 
year. The terminations of mania, other than the termination in recovery, 
are first in chronic mania, second in dementia, and third in death. The 
last event may be due to simple exhaustion, to the supervention of pneu- 
monia, pleurisy, cerebral congestion or other diseases, and to injuries 
accidentally inflicted. It may be added that patients who have once had 
an attack of mania are very apt to have relapses; and, again, that, when 
maniacal patients are suffering from tubercular or other intercurrent dis- 
eases, these, however acute their progress, appear to cause but little suffer- 
ing, and are apt therefore to be overlooked. 

Mania, like melancholia, presents many sub-varieties, characterized by 
special peculiarities. We shall refer briefly to a few of them. Delirium 
tremens, which has been elsewhere described, is manifestly a form of acute 
mania ; other varieties determined either by the special symptoms which 
are present, or by their cause, are nymphomania and puerperal mania. 
The acute delirium of French writers is mania, characterized by suddtn- 
ness of outbreak, by ' furious delirium with incessant incoherent chatter- 
ing, but with the dominant expression of anxiety ;' by ' vertigo, awkward 
trembling movements as if the patient were intoxicated ;' by sleeplessness, 
paleness of countenance, dry tongue, and rapid exhaustion. These cases 
are often attended with fever, last from a few days to several weeks, and 
frequently terminate fatally by collapse. Lastly, the so-called "Mania sine 
delirioj or ''folie raisonnante,' must be regarded as one of the varieties, 
and by no means an unimportant variety, of mania. It is the condition 
in which the patient presents affective disturbances with corresponding 
movements or motor impulses ; but in which there is an absence of delu- 
sions and probably of hallucinations. It corresponds to the early stage of 
many cases of ordinary mania, and it may persist without going on to de- 
lusive insanity for an indefinite period. In such cases the patient presents 
some marked change in his moral nature, he becomes light-hearted, vola- 
tile, vain, arrogant, quarrelsome ; he neglects his business, or buys and 
sells, or speculates wildly ; he devotes himself to pleasures ; he becomes 
acquisitive, perhaps steals; he talks and acts obscenely, and forms immoral 
connections ; he neglects or ill-uses his wife and children ; he takes to 
drinking ; he acquires expansive religious notions ; he entertains an ex- 
alted view of himself — his mental capacity, his personal appearance, and 
all that belongs to him. These, or such-like, are the perversions of mind 
or conduct which he displays, and which are all the more striking that they 
represent gross exaggerations of his natural characteristics, or are in abso- 
lute contradiction to them. Patients thus affected are capable of reason- 
ing, and will probably, if interrogated, assign plausible grounds for their 
conduct, or invent ready excuses, and will perhaps display more or less 
shame on the detection of their misdeeds. Although they are for the most 
part free from hallucinations or delusions, such phenomena are apt to 
supervene more or less suddenly, and in connection with these, or from 



INSANITY. 



1029 



other causes, they are always liable to have sudden outbreaks of maniacal 
fury. This condition may end after a short time in recovery ; it may 
persist for a length of time with little obvious change ; it may pass into 
mania or monomania, or it may result in dementia. 

3. Monomania is the term used to designate a form of insanity, specially 
related to mania, in which the patient with exalted notions of his own 
importance entertains fixed delusions which dominate his thoughts and 
conduct. It differs from melancholia in the absence of the profound and 
persistent depression which characterizes that condition, and from mania 
in the absence of that wealth of incoherent ideas, and of that restlessness 
and vivacity of movement which belong to mania, and the existence in 
their place of persistent delusions with the power of reasoning and of form- 
ing and carrying out enterprises or plans of action. Monomania may 
take its origin in mania or melancholia ; or it may come on independently, 
in which case it is usually preceded, as other forms of insanity are, by a 
stage of melancholy. Here, as in other cases, there is affection of both 
the moral and the intellectual side of the mind — monomaniacs have usually 
an overweening opinion of their own importance ; they are self-satisfied, 
vain, haughty, arrogant. One is affable, polite, condescending in his de- 
meanor. Another struts about with an air of insufferable pride, and treats 
those about him with lofty disdain. Some, especially females, are fond 
of dress, and deck themselves out fantastically or else show remarkable 
taste. Some, on the other hand, engrossed in other matters, are slovenly 
and dirty in their attire and habits. Sometimes they express themselves 
habitually in pompous or theatrical language. Sometimes they present an 
air of perfect calm ; their conversation and conduct indicating an exalted 
tranquil joy. The delusions under which such patients labor are neces- 
sarily various, though of an exalted character. In some cases they look 
upon themselves as great discoverers — they have solved the problem of 
perpetual motion, have squared the circle, or have invented machines 
which are capable of doing impossibilities. In some cases they regard 
themselves as having extraordinary knowledge, genius, or power ; and 
they are not merely wiser than any who have gone before — or distinguished 
generals or statesmen, or royal personages, or great poets — but they assume 
themselves to be Solomon, Wellington, or Napoleon, the Queen, or the 
Deity himself. Not infrequently they believe themselves to be benefactors 
of mankind ; that they have revealed conspiracies, and that their praises 
are on everybody's tongue, or that they are apostles or prophets. Some- 
times their delusions are of a lower grade, and they believe that they are 
objects of suspicion ; that they are being constantly tracked ; that people 
sneeze or cough or make signs which have some mysterious relation to 
them. Hallucinations and illusions are often associated with the delusions 
of these patients, and react upon their mental condition. We have referred 
to the fact that monomaniacs retain for the most part a considerable power 
of reasoning. In many cases they discuss matters unconnected with their 
special delusions with perfect intelligence ; and even in relation to their 
delusions they can usually adduce plausible and even striking arguments ; 
but that the mental powers in these cases are weakened in a greater or less 
degree is undoubted. Firm in their belief, they are apt to meet objections 
with a flat denial or a simple assertion of their claims, and generally ignore 
their opponent's argument. They entertain in fact a fundamental belief 
which is beyond controversy. Monomaniacs, especially in asylums, are 
often quiet and harmless in their behavior ; but when thwarted or contra- 



1030 



DISEASES OF THE NERVOUS SYSTEM. 



dieted, and occasionally even when unprovoked, they are apt to become 
violent and dangerous, and to exhibit maniacal or ungovernable fury. 

Monomania seldom ends in recovery ; and especially rarely if it has 
existed for over six months. It often becomes chronic, and continues with 
little change for many years. It generally however passes sooner or later 
into dementia. The bodily health is generally good. 

4. Dementia. — By this is meant, not as in the forms of insanity hitherto 
considered, a qualitative change or perversion of the mind, but its dete- 
rioration or decay. It is the natural termination of all incurable cases of 
melancholia, mania, and monomania ; it commonly supervenes sooner or 
later in all forms of cerebral disease, such as epilepsy, sanguineous apo- 
plexy, embolic softening, disseminated sclerosis, and tumors ; it occasion- 
ally follows certain of the acute febrile disorders ; and it is apt to come on 
after any severe shock to the nervous system, after long indulgence in 
drink or masturbation, and as one of the accompaniments of old age. It 
is interesting, as Griesinger remarks, that the dementia of old age is not 
infrequently preceded by a stage of mild maniacal excitement. Perhaps 
the most remarkable characteristic of dementia, and that by which it con- 
trasts strikingly with the acuter forms of insanity, is the more or less 
complete loss which its victims manifest of those moral attributes and sen- 
timents which form so important a part of our healthy mental condition, 
and which by their perversion or intensification constitute the very basis of 
mania and melancholia. The patient is no longer impelled by passion or 
by feeling; his acts are not determined by any persistent mood; he is inca- 
pable of intense hate or deep love; he manifests no interest in those about 
him, and the loss of friends or relatives, even of those who are dearest to 
him, affect him little or not at all. It is not meant that there is a total 
absence of emotions, but they are superficial, they come and go, they exer- 
cise no lasting influence, they do not determine the patient's actions, but 
they spring momentarily from the impression made on the senses or the 
ideas that come to the front. Impairment of the intellect waits upon 
the moral abeyance. There is always more or less feebleness of the mental 
powers ; memory fails ; the patient probably forgets every thing that has 
occurred during the day, and most that has happened to him during his 
illness ; but he still calls to mind in a disorderly manner the events of his 
former life, and the delirious ideas that thronged his mind during his 
melancholic or maniacal state. He cannot reason ; he is incapable of ab- 
stract thought. For the most part the loss of the reasoning power is 
obvious ; the patient's thoughts and words are incoherent ; he harps upon 
certain formulae, and does not care or is unable to join in continuous con- 
versation ; and it is a remarkable fact, universally recognized of demented 
persons, that they are incapable of combining together to form plots, and 
that large numbers of them collected in a ward may be led and managed 
by one or two attendants like a flock of sheep. In association with the 
loss of memory and of the reasoning faculty, we find that delirious ideas, 
hallucinations, and illusions abound. Delusions, however, are rarely, if 
ever, developed afresh. Those which are present remain for the most part 
from the active stage of madness which preceded dementia ; and they 
now probably form the centre, so to speak, of the patient's mental opera- 
tions. They form fundamental facts, their reality is indisputable, and the 
patient's remnant of thought revolves about them, and clings, as it were, 
to them for support. The existence of hallucinations is shown by the fre- 
quency with which demented patients see absent persons, and things and 



INSANITY. 



1031 



visions, and hear voices with which they probably converse audibly. The 
presence of illusion is manifested by the frequency with which they take 
persons about them for those who are absent or dead ; take pieces of 
glass and stone for precious stones and gold, and regard old broken jugs 
and articles of furniture as their children who died long ago. Many of 
the strange occupations which demented patients delight in are indicative 
of the condition here adverted to. Thus, one, as Dr. Maudsley says, 
1 whose singular movements seem unaccountable, is busy spinning threads 
out of sunbeams,' while another ' continues the most violent movement of 
his arms in order to prevent the motion of the universe or of his own blood 
from coming to a stand,' and yet another turns about and performs strange 
antics under the belief that he is absorbing the green of the surrounding 
trees, with the object of utilizing it in some mysterious way. 

The actions of demented patients present remarkable variety, although 
showing considerable uniformity in the same individual. In some cases 
they are restless, in constant movement, incessantly chattering, making 
incoherent yet occasionally pertinent remarks upon persons and things, 
yet having reference to their delusions ; in some they are perpetually 
making collections of stones, rags, feathers, and other rubbish, in the ap- 
parent belief that they are accumulating treasures of great value, or they 
appropriate their neighbor's food and other articles of property ; in some 
cases they mope in corners ; in some they pace incessantly backwards and 
forwards like a caged lion ; in some they adorn themselves fantastically ; 
in some they sit rocking themselves on a barrel all day long. In connec- 
tion with this subject it may be observed, that some patients are lascivious 
in their conduct, and commit masturbation shamelessly ; that although 
there is no dominant feeling which guides their conduct, some are apt 
to smile and laugh, some to cry, some to break out suddenly in tits of vio- 
lent passion, and some are mischievous or malicious in their general beha- 
vior. Sooner or later they tend to become dirty in their habits and to 
pass their evacuations without restraint. 

Patients suffering from dementia for the most part enjoy good bodily 
health, and often become fat. They have good appetites, and their bodily 
functions are well performed. But they have a more or less vacant ex- 
pression and a look of old age. As regards the duration and termination 
of the disease, it may be stated that imbeciles and demented persons usu- 
ally live for many years, remaining at the original level of intelligence or 
very slowly becoming more and more childish and stupid ; that they rarely 
if ever get well ; and that death is due either to pneumonia, pleurisy, 
tuberculosis, or other intercurrent affections, or to attacks of congestive or 
sanguineous apoplexy or to other brain-affections. When the disease is 
primary, however, recovery is not uncommon. 

Dementia varies in its degree and in its character. In one form of it, 
especially as it is occasionally observed after apparent convalescence from 
an attack of acute mania, the patient is so far restored to his normal state 
that he retains his reasoning powers, and is able to conduct his business, 
and to perform the ordinary duties of life ; but his sensibilities are blunted, 
and he has lost all interest in and capacity for all those pursuits and en- 
joyments which are the evidences and results of culture. He has lost all 
the freshness and spontaniety, all the higher and holier impulses, all the 
ideas and sentiments, that rendered him interesting and sociable ; and is 
content to pass his life automaton-like within the limits of a contracted 
sphere of thought and action. He is physically the same man that he 



1032 



DISEASES OF THE NERVOUS SYSTEM. 



formerly was, and he can perhaps reason as acutely as ever ; he may even 
appear mentally healthy to those who see him for the first time, but essen- 
tially and to his friends there is a profound change. 

The greater number of permanent residents in asylums are persons whose 
dementia follows on mania, melancholia, or monomania, and in whom the 
delusions or insane ideas of their former condition still survive. They 
have lost the deep emotions which affected them then ; their mental pow- 
ers have decayed, but amid the general wreck of mind their delusions 
retain a more or less powerful hold upon them, and associated with hallu- 
cinations constitute the prominent parts of their mind and determine their 
actions. It is such patients that one sees performing all kinds of strange 
antics : polishing the floor with their saliva, taking the altitude of the 
absent sun with their closed eye, directing magnetic currents, adorning 
themselves with fantastic ornaments, collecting rags and sticks, sitting 
perpetually dumb because they are God the Father who speaks only through 
his Son, remaining fixed in one position because they are made of glass or 
wood, or believing that they contain strange monsters in their interior. 

In another group of cases there is a still greater loss of the mental facul- 
ties ; but for the fragments of delusions and ideas that so to speak play 
upon its surface the mind is a blank. The memory is almost in abeyance ; 
they forget everything of the recent past, and most of what happened in 
their previous lives ; often they have lost all ideas of their own identity, 
and have absolutely forgotten their own names. Objects about them make 
the usual impressions on the organs of sense ; but the impressions are 
scarcely if at all taken cognizance of by the mind. There is often more 
or less insensibility to pain. Delusions may continue in a fragmentary 
form ; but no new ideas are developed. All capacity for real sensibility 
or passion is of course absent; but the patient nevertheless is apt either to 
present a uniform joyous aspect, or he is disposed to cry, to show malice, 
or to be mischievous. Such patients are generally in constant movement, 
restless, and frequently pass a large portion of their time in chattering, 
laughing, or singing. Not infrequently there are evidences of paralytic 
weakness of the limbs. 

In yet another group of cases, and this constitutes the last stage of 
dementia, the patient's intellect is almost entirely annulled ; and his life is 
mainly vegetative. He takes no notice of what is going on about him, or 
of what happens to his own person ; fitfully perhaps he utters a few sounds, 
it may be a few words, and gleams of emotion play across his vacant and 
meaningless features; he performs a few monotonous movements, or re- 
mains in one posture hour after hour ; or if set walking continues to walk 
until his movements are arrested by force ; he requires to be fed, to be 
dressed and undressed, to be put to bed and to be taken out of it, and to 
have all his wants attended to like a young baby. Nutrition in this as in 
the other cases may remain unimpaired. 

5. General paralysis This is a well-marked form of insanity, formerly 

confounded with mania, but clearly distinguished from it in the first 
instance by MM. Bayle and Calmeil, and now universally recognized as a 
specific disease. It differs from other forms of insanity anatomically in 
the fact that the symptoms depend directly on chronic inflammation of the 
gray surface of the brain, and clinically in the association with mental 
alienation of progressive paralysis of all the voluntary muscles. 

General paralysis occurs much more frequently in men than in women. 
It is rarely if ever met with in persons under twenty ; and most commonly 



INSANITY. 



1033 



first makes its appearance after sixty. Its causes are various and often 
obscure. One of the most important is long-continued alcoholic intempe- 
rance. It is also attributed to venereal excesses, overwork, anxiety, men- 
tal shock, and physical injuries. 

It usually commences with a prodromal period of variable, it may be 
several months', duration, in which as in the early periods of other forms 
of insanity, the moral and affective nature of the patient becomes more or 
less profoundly modified. His character and habits become changed, he 
is restless and irritable, and disposed to take offence and be violent; he 
attends maybe to his duties, but he gives himself up to debauchery, he 
lies, he speculates, he cheats or steals, and becomes a cause of deep anxiety 
to his friends. 

Sooner or later the actual invasion of the disease takes place. This, 
according to M. Falret may show itself in four different ways, in two of 
which the physical symptoms predominate, in two the psychical : — 

(a) In the congestive variety, the patient is suddenly attacked with an 
epileptic or apoplectic fit, which differs in nothing from the similar seiz- 
ures which attend so many chronic affections of the brain. From this 
after a few hours or a few days he recovers, when it is probably observed 
that he presents maniacal excitement with grandiose delirium, or that there 
is some little impairment of memory and intellect together with slight 
difficulty of speech and trembling of the lips. Not infrequently there is 
progressive improvement in the patient's condition until another fit leads 
to aggravation of his symptoms. Occasionally the initial congestive attack 
shows itself not in an actual fit, but in an outbreak of mania attended with 
hallucinations and delirious ideas. 

(b) In the paralytic variety, symptoms of paralysis precede all others, 
and probably attain a high degree of development before the obvious indi- 
cations of mental alienation declare themselves. The patient under such 
circumstances himself observes that he is gradually losing muscular power, 
and that he cannot take the amount of exercise, or do the amount of work 
that he formerly could do. He observes that his legs tremble, and that he 
has a difficulty in ascending a hill or going upstairs ; that his arms and 
hands are tremulous and that he cannot write or perform other manual op- 
erations with his former dexterity : and further that his lips tremble when 
he speaks, and that his enunciation is imperfect. The paralytic phenom- 
ena gradually increase upon him, and ere long, it may be after a few weeks 
or a few months, the symptoms of cerebral excitement or alienation, which 
may have been gradually and imperceptibly creeping on even from the 
beginning, become clearly developed. The paralysis presents very striking 
features. It is generally first observable in the lips and tongue, and then 
extends with more or less uniformity of progress until it involves all the 
voluntary muscles. It is characterized by the association of tremulous 
movements (developed only when the patient exercises his muscles) with 
loss of power. The lips tremble at the moment of attempted utterance. 
So soon as the patient endeavors to open them a little hesitation or hitch 
in their movement or distinct trembling, as though the patient was about 
to sob, may be observed. This appearance is generally regarded as of fatal 
omen. The tremor may be more or less violent and may involve other 
parts besides the lips. Sometimes indeed the whole face, and even the or- 
biculares palpebrarum, are thrown into vibration when the patient speaks, 
and the jaws themselves may chatter as in the cold stage of an ague fit. 
The tongue trembles similarly when protruded. The effect of these move- 



1034 



DISEASES OP THE NERVOUS SYSTEM. 



ments on speech are remarkable. In some cases the patient simply hesitates 
a little, in some he slurs his words, or drawls them, or utters them in a 
monotone, or speaks as though he were scanning. Sometimes his speech is 
so tremulous that it can scarcely be understood ; sometimes the preliminary 
movements of his lips and tongue are so prolonged and violent that he finds 
it impossible to get his words out. Not infrequently he stammers or blunders 
in the use of words. The difficulty of speech is usually greatest when the 
patient is being watched or when he is nervous. The legs and arms are 
for the most part affected simultaneously ; but sometimes the arms suffer 
earlier than the legs and conversely ; and occasionally the paralysis com- 
mences in the hemiplegic form. No doubt the loss of power is generally 
observed earliest in the legs ; they become weak and tremble in use ; the 
patient has difficulty in walking ; he cannot readily rise from his seat, he 
walks bent forward with his legs apart, and takes short quick steps, and 
often has a tendency to run ; he is easily thrown off the balance and espe- 
cially has a tendency to totter when suddenly checked in his onward pro- 
gress, or made to turn. The arms also get weak and tremulous ; and conse- 
quently the handwriting becomes shaky, and the patient soon has to give 
up writing, and any other manual labor, especially such labor as requires 
delicacy of touch, engraving, painting, playing musical instruments and 
the like. The paralytic symptoms are not altogether unlike those which 
attend disseminated sclerosis and occasionally the affection of the legs is that 
of ordinary locomotor ataxy including loss of patellar reflex. Among the 
paralytic symptoms must be included inequality in the pupils, and loss of 
action of the irides under the influence of light. Generally some degree 
of impairment of sensibility accompanies the motor paralysis. 

(c) The expansive variety — the variety commencing with exaltation of 
mind and delirious ideas of an expansive kind — is by far the most common 
of all the varieties of general paralysis. In this paralysis comes on some 
little time after the insane symptoms have existed ; and it may remain 
doubtful for a time whether or not the case is really one of the disease 
under consideration. The prodromal symptoms, which are mainly those 
of so-called ' moral' insanity, gradually undergo further developments. 
Patients who had hitherto been in a capricious frame of mind that had ex- 
cited the uneasiness of their friends, become more restless, more excitable, 
more violent and wayward than they were. They talk, write, compose inces- 
santly ; they are constantly moving about, constantly entertaining new pro- 
jects. But at the same time there is a manifest failure of memory, especially 
in relation to things which have just happened. Their bodily activity isfor the 
most part remarkable ; they are always on the move, sometimes actively en- 
gaged in trivial matters, sometimes restlessly hurrying about from place to 
place, sometimes going on journeys and disappearing for a time without giving 
any intimation to those about them as to their proceedings. They are apt to 
do all kind of outrageous things, to indulge in venereal excesses, to give 
themselves up to drinking, to steal, to undress in public places, to come to 
a dinner party in dressing gown and slippers, to spend money extravagantly 
and to make valuable presents to persons who have no claim upon them, 
to enter upon wild speculations, and to manifest alternately boisterous gayety, 
reckless audacity, and sudden anger. Up to this point there may have 
been no true maniacal delirium. But ere long the grandiose notions and 
delusions which are so characteristic of this affection manifest themselves. 
These usually have relation to money and wealth. The patient, who per- 
haps is in receipt of a small precarious income, at first believes that his income 



INSANITY. 



1035 



J is assured to him and double or treble of what it really is. And by rapid 
i strides he assumes that he is worth thousands, millions, millions of mil* 
j lions, that all the gold in the world is his. Or he enters upon imaginary 
j speculations, buys up all the railways in England, all the railways in the 
j world, and gives part of £200,000 a year to any one who strikes his fancy. 

Or he has a house of gold, surrounded by trees of gold and precious stones ; 
! he has extensive possessions, a county, a country, the whole universe. In 
j connection with the idea of wealth, arise ideas of glory, honor and power. 
[ Such patients become distinguished soldiers, generals, emperors ; they are 
great statesmen, poets or philosophers ; they are brothers of Christ, Christ 
himself, or the Almighty ; they are hundreds of feet high ; their strength 
is enormous ; they can create giants and worlds ; they can cure the sick, 
and raise the dead. Their notions too are often fantastic as well as gran- 
diose; they have several rows of natural gold teeth ; they have an unfailing 
growth of hair which they can spin out of their heads like silk-worms from 
their tails. The delirious fancies of general paralytic patients are always 
associated with more or less dementia. Their delusions are not systema- 
tized ; and their actions are not necessarily in conformity with their delusions ; 
moreover their delusions are variable, and are mingled in the most grotesque 
way with the circumstances of their daily life. Thus the man who believes 
that he is worth millions, and is ready to bestow thousands, will gladly ac- 
cept a few shillings, will talk reasonably about his daily earnings, will beg 
piteously for a little tobacco. He who believes himself to be Christ will talk 
perhaps rationally on his private affairs, and be ready, if such has been his 
occupation, to polish your boots or sweep your chimney. The patient who 
is an emperor or king, will tell you that his wife is a washerwoman and her 
children attend a charity school. The characteristic paralytic phenomena 
always appear sooner or later in this case — generally as soon as distinct 
delusions manifest themselves — and rapidly progress from bad to w 7 orse. 

(d) The melancholic variety is much more rare than the last, and is 
in striking contrast with it. In this the patient is low-spirited and miser- 
able; he thinks he is ruined or dishonored, he has committed unpardon- 
able crimes, he is doomed to death or to eternal punishment. His condi- 
tion, indeed, is much like that of an ordinary melancholic patient, excepting 
that here, as in the last case, the symptoms are more variable, the delusions 
are less persistent, and occasional gleams of high spirits or grandiose 
delirium flash across his mind and reveal themselves in his aspect and 
behavior. Occasionally the depression of spirits assumes a hypochondri- 
acal character ; the patient has uncomfortable feelings within him which 
become connected w r ith some fantastic belief, such as that he has no insides, 
that he can neither swallow, defecate, nor pass water, and so on. This 
melancholic condition may last throughout the whole period of the patient's 
illness; or it may get replaced, sooner or later, by the ordinary form of 
exalted delusions. When it persists, it generally implies that the patient's 
illness is of a specially grave character, and that it will terminate rapidly 
in death — a result which, in these cases, is often accelerated by the pa- 
tient's refusal to take food, by malnutrition, and by the appearance of 
bed-sores. In this case, as in the last, the symptoms of paralysis more or 
less speedily complicate the patient's malady and stamp its real nature. 

In concluding this subject, it must not be forgotten that, however the 
disease begins, sooner or later, if not from the very first, mental aliena- 
tion and muscular paralysis become associated, and thenceforward run 
their downward course together. Nor must it be forgotten that, although 



1036 



DISEASES OF THE NERVOUS SYSTEM. 



cases are frequently met with in which the mental phenomena precede the 
symptoms referable to the muscular system, and cases are occasionally 
met with in which muscular weakness appears to forestall insanity ; in a 
very large proportion of cases, the commencement of the two conditions is 
simultaneous. 

In the second stage of the disease, the special traces of the several varie- 
ties of origin are, for the most part, lost ; the paralysis has become con- 
siderable, and the mind, though still presenting delirious conceptions of an 
exalted or, more rarely, of a depressed character, has sunk deeper into in- 
coherence and dementia. The tremors of the lips and tongue, and the 
paralysis of the muscles of mastication and deglutition have advanced so 
that he has great difficulty of articulation, perhaps cannot articulate, and 
he has difficulty in chewing and swallowing ; he probably cannot, without 
assistance, get upstairs or into his bed, he walks with difficulty across his 
room, he has lost the power of dressing himself, and even, maybe, of car- 
rying food to his mouth. There is impairment of co-ordination as well as 
weakness. Sometimes his muscles become contracted. His mental condition 
is that of dementia ; he has lost nearly all notion of time, space, or locality ; 
he has forgotten almost or entirely his father, mother, wife, and nearest re- 
lations ; he shuffles about listlessly ; he undresses himself at unsuitable 
times and places ; he gets into his neighbor's bed, and appropriates his 
neighbor's food; he collects all kinds of rubbish. His condition is gener- 
ally one for mild treatment ; but he occasionally presents sudden outbreaks 
of maniacal violence ; and his mind is still, in a greater or less degree, the 
seat of delusions, relating to riches and grandeur, and more rarely to such 
as are of a sad or painful nature. 

The last stage of general paralysis is that in which the patient has lost 
the power of locomotion, and is confined to bed or to a chair ; in which 
the power of speech is annulled, in Avhich he can no longer feed himself, 
and in which, above all, he passes his evacuations incontinently into his 
bed or trowsers, and his mind has sunk to the lowest depths of dementia ; 
he knows no one, probably gives no indication of his wants, passes his 
time in fumbling with his fingers, pulling to pieces his clothes or bed-linen 
and uttering from time to time incoherent noises or cries. 

There are two or three points in connection with the history of general 
paralysis which must not be omitted from our description. First, as re- 
gards the sensory organs. We have already pointed out that even early 
in the disease there is usually more or less manifest impairment of com- 
mon sensation. This anaesthesia usually becomes more pronounced as the 
malady progresses, until at length the patient takes no notice when he 
is pinched or pricked or otherwise injured. It is curious, however, that 
he occasionally suffers from paroxysms of extreme hyperesthesia. The 
other organs of sense, for the most part, remain unaffected; but smell and 
taste occasionally diminish in acuteness or become lost. The digestive 
organs usually act well ; the appetite is unimpaired, and in the second 
stage is often ravenous ; at this time, too, the patient crams his food into 
his mouth and swallows it with little attempt at mastication. As a con- 
sequence, general paralytics are pretty well nourished and even become 
fat. In the last stage, however, emaciation may ensue, bed-sores may 
form, and diarrhoea, pneumonia, or tuberculosis may supervene. The 
skin is generally dry, and not infrequently is covered with a copious seba- 
ceous exudation. 

The progress of general paralysis is almost without exception uniformly 



INSANITY. 



1037 



from bad to worse, and the patient, as a general rule, dies within three 
years of the first accession of symptoms. Cases, however, are sometimes 
observed in which remissions take place, and a period of comparative res- 
toration to health intervenes between the primary attack and the relapse. 
A few cases of recovery have been recorded. 

The causes of death in this disease are various. In some cases, the pa- 
tient dies of simple exhaustion, accelerated by bed-sores and other com- 
plications. In some cases, his death is due to asphyxia, resulting from 
the impaction of a bolus of food at the top of the larynx. The most in- 
teresting causes of death, however, are the apoplectiform seizures to which 
the patients are liable. These are identical with those which occasionally 
usher in the disease. They are liable to occur at any period of its course, 
but more especially towards the termination, and to recur from time to 
time. They invariably aggravate the patient's condition. They are 
ushered in with excitement and elevation of temperature ; by which oc- 
currences their advent may often be predicted. Their symptoms are 
coma coming on sometimes, suddenly, sometimes gradually, and not infre- 
quently convulsions or hemiplegia, with elevation of temperature to 103, 104, 
or more. These attacks are not unlike those due to uraemic poisoning, and 
correspond pretty accurately to what was formerly called serous apoplexy. 

6. Idiocy is a form of dementia which dates from birth, or comes on 
shortly after birth, at any rate before the mental faculties have reached 
their full development. It differs, therefore, from dementia, especially in the 
fact that the mind presents few or none of those insane reminiscences which 
are so common in dementia, and tend to give to each case distinctive fea- 
tures. Moreover, hallucinations, illusions, and insane ideas or delusions 
are by no means necessary, or even generally present. The causes of 
idiocy are various. Generally it depends directly on some anatomical 
defect, arising during intra-uterine development, or coming on shortly 
after birth ; or it may be due to injuries inflicted on the brain or its parietes. 
Occasionally it is the result of convulsions or epilepsy coming on in early 
life, over-forcing of the mind, fright, or other powerful mental impressions, 
or a sequela of some serious illness, such as one of the infectious fevers. 
It is often referable to inheritance, thus it is not uncommon among the chil- 
dren of parents who are close relations ; it is often observed in families 
where other malformations, epilepsy, or tendency to scrofulous disease 
prevails ; it is a frequent consequence of drunkenness of father or mother; 
and like goitre it is the product of certain localities. 

Idiocy, like dementia, may vary from mere feebleness of intellect to a 
condition in which the mind is almost wholly absent. In the latter case 
the patient is apathetic, with a dull, vacant, fatuous aspect ; he requires to 
be fed, clothed, and attended to in all particulars ; he cannot speak, mum- 
bles inarticulately, or grunts from time to time without obvious cause, or 
when he feels the pangs of hunger ; he take no notice of any one or any- 
thing ; he has no affections, and remembers nothing ; he remains still, or 
performs various monotonous, meaningless movements; his sense of feeling 
is imperfect, his smell and taste are defective, and his hearing is obtuse. 
The tongue is often enlarged, and the incisor teeth protruded. The body 
is probably imperfectly developed, or deformed, and certain of the mus- 
cles, or all of them, are shrunken, rigid, or paralyzed. Choreic and epi- 
leptic convulsions are not infrequent. The sexual organs are usually un- 
developed, though occasionally masturbation is practised. In the highest 
class of cases there is simply imbecility. The patient is often well de- 



1038 



DISEASES OF THE NERVOUS SYSTEM. 



veloped and well grown ; his nutritive formations are perfect ; but lie is 
restless and volatile, capricious in temper, clumsy in his actions, slow in 
the acquisition of speech, imperfect of memory, and difficult to teach, 
awkward and inapt in the amusements and games in which his playmates 
delight, incapable of application or of continuous thought, and given to 
indulge his appetites, to eat greedily and to masturbate ; he is often spiteful. 
Between these extremes innumerable varieties exist. But they may be 
roughly arranged in two classes : namely, first those who are dull and 
apathetic, and for the most part deformed ; and second those who are 
restless and excitable, who readily respond to impressions made upon the 
senses, and who laugh, cry, scream, gesticulate, clap their hands, get into 
mischief, and at times give way to outbreaks of uncontrollable anger or 
fury. Idiots have been divided by Esquirol into three classes : namely, 
idiots who can use short words and phrases; those who can only utter 
monosyllables and certain cries ; and those who are unable even to express 
themselves in monosyllables. Epilepsy is a common complication of idiocy. 
It is a curious circumstance, but one scarcely to be wondered at when one 
considers the variety of anatomical and other defects on which idiocy de- 
pends, that idiots not infrequently present special talents which prima facie 
might appear incompatible with the presence of idiocy. Thus there are 
some actual, and even extreme idiots, who manifest a real talent for the 
performance of music, some who have a marvellous power of drawing and 
painting, some who show remarkable ingenuity and skill in making models 
of ships or houses, some who possess an astonishing memory for dates or 
poetry, and some even who can perforin mental calculations of considerable 
difficulty. Idiots, w r ith the exception perhaps of cretins, rarely attain an 
advanced age. Education has a considerable influence over their condi- 
tion. Most of them are capable of having those faculties which they 
possess improved by judicious training, and it is interesting to see in w 7 ell- 
con ducted asylums how 7 happy and useful in a way, and intelligent within 
certain limits, patients become who under other circumstances would have 
been dirty and spiteful, and incapable of any occupation or amusement, and 
perhaps given to filthy habits. On the other hand it is worthy of observation 
how much an idiot may retrograde under adverse conditions, how rapidly 
the loss of eyesight or of hearing, coming on accidentally, may reduce an 
idiot of the higher grade to the lowest depth of mental degradation. 

Before concluding our clinical description of insanity it is desirable to 
make a few 7 observations in reference to the prognoses of its several varie- 
ties. Idiocy is, of course, incurable, although, as we have just pointed 
out, such powers of mind as the sufferer possesses may often, by careful 
education, be improved in no inconsiderable degree. It has no necessary 
influence in controlling the duration of life, although as a matter of fact, 
owing to various causes which need not be specified, idiots as a rule die 
early. General paralysis of the insane, notwithstanding a few reported 
cases of recovery or arrest, may also be regarded as practically incurable. 
We have already adverted to the fact that intermissions, and periods of 
partial amendment are not uncommon in this disease, but as an almost 
universal fact general paralytics die within three years of the first appear- 
ance of symptoms. A large number die within the first year. Dementia, 
the result of advancing age, or of organic disease of the brain, may gene- 
rally be regarded as incurable, notwithstanding the fact that cases of de- 
mentia due to syphilitic disease of the brain occasionally recover, tempo- 



I 



INSANITY. 



1039 



rarily at any rate, under appropriate treatment. The dementia, again, 
which follows upon melancholia, mania, and monomania is incurable. It 
is important to observe, however, that demented patients often live for 
years fairly healthy in body, and with little, or rather, perhaps, very slow 
deterioration of their mental state. Primary dementia — dementia due to 
moral shock, or to acute systemic disease — is much more hopeful. Of the 
three varieties of insanity — melancholia, mania, and monomania — melan- 
cholia is the most liable to recovery ; monomania the least liable. At the 
same time there are considerations which modify for certain cases the 
general applicability of this rule. For example, insanity of sudden onset 
is usually more curable than that which has come on insidiously ; insanity 
which has already lasted for some time with no improvement is less hope- 
ful than insanity of recent occurrence; cases in which mania and melan- 
cholia alternate ( folie circulaire), and cases of recurrent insanity are 
specially gloomy as to their prospects of ultimate recovery. Again, melan- 
cholia with the fixed delusion that the sufferer is the victim of some 
extreme agony, or in which under some such mental influence he has 
homicidal tendencies, is of ill omen. Insanity traceable to hereditary 
predisposition presents on the whole a less favorable prospect than insanity 
where no such original taint can be traced. When insanity has been 
brought on, or aggravated by sexual excesses, and especially by self-abuse 
(excepting in the earliest stage of the disease), and especially when in- 
sanity is associated with epileptic fits, the chances of recovery are very 
faint. Madness arising in young persons, occurring in those who are 
suffering from some curable bodily disorder, or developed in hysterical or 
puerperal females, is to a very large extent curable. It need hardly be 
added that the prospects of life in insanity are largely dependent on the 
conditions of health associated with the mental disease ; and, as has 
already been pointed out, that tuberculosis is exceedingly common and fatal 
amongst insane patients ; that intercurrent diseases of various kinds are 
apt to arise and carry them off ; that they are exposed to many accidental 
(suicidal or other) causes of death ; and lastly, that occasionally in very 
acute forms of insanity attended with absence of sleep death from simple 
exhaustion ensues in the course of two or three weeks. 

Pathology and morbid anatomy It is in this department of the study 

of insanity that our knowledge is least advanced — a fact due not to any 
want of skill or labor, or of admirable investigators, but to the inherent 
difficulty of the inquiry. We are acquainted, no doubt, with many facts 
which directly or indirectly throw light upon the subject. We know, for 
example, that it is the gray surface of the brain which is the supreme 
organ of all mental operations, and that in order that this shall act effi- 
ciently it is essential that the nerve-cells of the part shall be healthy in 
themselves, and shall retain their due communication with one another, that 
their vascular supply as well for nourishment as for the removal of effete 
matters shall be sufficient, that they shall not be exposed to mechanical 
pressure or other like injurious influences, and that they shall not be acted 
on by poisonous matters. And we know, as the basis of these conclu- 
sions, and as confirming them, that symptoms, differing little if at all 
from those of the several varieties of insanity which we have considered, 
may be caused by inflammation of the meninges or substance of the brain, 
by tumors affecting the same parts, by effusions of blood, by injuries or by 
softening involving the superficies of the brain, by anaemia due to loss of 
blood, by the circulation of poisonous matters retained in the blood — such 



1040 



DISEASES OF THE NERVOUS SYSTEM. 



as carbonic acid, bile and urea — and by the direct action of poisons ab- 
sorbed from the stomach, especially alcohol, opium, and belladonna. In 
true insanity, however (excluding general paralysis and idiocy, which, for 
reasons presently to be stated, stand in a different position, and may be 
regarded as distinct from it), no lesions of sufficient constancy or import- 
ance to explain the mental phenomena of the disease have ever been de- 
tected. It is not by any means that no pathological changes are discovered 
in the brains of persons who have died insane. On the contrary, manifest 
lesions are of constant occurrence ; amongst which may be enumerated 
congestion, opacity, and adhesions of the visceral arachnoid and pia mater, 
thickening of the ependyma of the ventricles, excess of serum in the sub- 
arachnoid tissue, wasting of the brain, increased density and abnormal 
firmness of the brain-tissue, atheromatous and earthy changes in the arteries 
at the base, and similar affections, with the formation of small aneurisms in 
the substance of the organ, evidences of the transudation of blood fur- 
nished by the presence of pigment, etc., in the course of the smaller vessels, 
increase of the cerebral connective tissue with the appearance of fatty 
molecules and corpora amylacea, atrophy with pigmentation or loss of pig- 
ment of the brain-cells; patches of sclerosis scattered here and there, 
extravasation of blood, abscesses and tumors. But such lesions or altera- 
tions of structures are most of them found even more frequently in the 
brains of persons who have never been insane, who perhaps have presented 
no cerebral symptoms whatever, and who have died of other than cerebral 
diseases. The fact is that in patients who die of acute insanity or of 
insanity in the early stages, little or no change of any importance is dis- 
coverable. In many cases the brain appears to be absolutely healthy, 
and in those which present abnormal appearances these are either simple 
anaemia, or more commonly congestion pervading the pia mater, gray matter, 
and centrum ovale. But even when congestion is discovered, it is doubtful 
what relation it bears to the patient's symptoms ; w 7 hether, in fact, it is 
their cause or their consequence. It is in the brains of patients who have 
died of insanity of many years' duration, and especially in the brains of those 
who have long been demented, and whose death is probably due to some 
intercurrent disorder, that the morbid changes above enumerated are 
almost exclusively found. The changes which are most uniformly met 
with under these circumstances are those indicative of degeneration — 
namely, atrophy of the brain and of its essential elements, increase of the 
connective tissues, with adhesion and opacity of the meninges, and thick- 
ening of the small vessels, with the appearances along them of corpora 
amylacea, fatty matter, blood-pigment, and other evidences of sanguineous 
exudation. 

It is not, however, surprising that the post-mortem phenomena of in- 
sanity are so vague, not to say trivial. The gravity of the symptoms of dis- 
ease depend, as a rule, less on the nature of the disease than on the 
relative importance of the organ which it implicates. And as we well 
know, so-called " functional" disorders of the dynamical element of the 
nervous centres, or disorders which depend upon molecular changes or 
alterations of relation which have hitherto escaped the eye, and which in 
themselves are often transitory and of little moment, are always attended 
with much more serious symptoms than similar disorders of less important 
parts, or even the gross diseases implicating the white substance of the 
brain. We need only refer in illustration to the phenomena of tetanus, or 
poisoning by strychnia, and to those of hysteria, chorea, and epilepsy; or 



INSANITY. 



1041 



to those arising from opium, alcohol, and the substances which act as 
poisons to the brain. In the same sense we may regard insanity as a 
functional affection of the gray matter of the surface of the brain, charac- 
terized either by exaltation of function, diminution of function, or perversion 
of function, and attended by differences which depend partly on the degree 
of functional modification present, partly on the particular areae of the brain 
surface which are chiefly, or it may be solely, implicated. That insanity 
does not necessarily involve any profound pathological change in the tex- 
ture of the brain, is proved by the frequency with which rapid recovery 
takes place, even when the mental disturbance has been of a very aggra- 
vated kind and long maintained. At the same time there can be no doubt 
that insanity of long duration leads to gradual structural changes in the 
brain substance, and that the supervention of such changes influences the 
patient's condition disastrously, and renders his restoration to mental 
health impossible. Among the lesions to which insane patients are liable, 
we may take this opportunity of adverting to one, not on account of 
its intrinsic importance, but because it is common in insanity, and charac- 
teristic of it — we refer to hematoma auris. This, which consists in the 
effusion of blood between the cartilages and the perichondrium, and leads to 
much thickening of the organ, occurs in all varieties of insanity, and its 
occurrence is generally looked upon as of ill-omen. It has been attributed 
to violence on the part of attendants; but there is no doubt that it occurs 
independently of this cause. 

The remarks above made do not apply to general paralysis of the in- 
sane, or to most cases of idiocy, in which morbid conditions of the brain 
are present amply sufficient to explain the clinical phenomena manifested 
during life. It is now fully established that general paralysis of the 
insane is due directly to a kind of chronic or slow inflammation com- 
mencing in the gray matter of the surface of the brain, and either re- 
maining limited to this, or involving also other parts of the brain, and 
even of the spinal cord. The morbid changes referred to differ little, if 
at all, in their essential features from the sclerosis which forms the patho- 
logical basis of tabes dorsalis, and other varieties of chronic spinal disease. 
The pia mater and surface of the brain become hyper<emic, and the pia 
mater and arachnoid thickened and unduly adherent to each other and to 
the brain ; the neuroglia and its corpuscles undergo abnormal development ; 
the walls of the smaller bloodvessels partake of this change, become thick- 
ened and impacted with the hypertrophied connective tissue around ; the 
nerve cells in the gray matter atrophy, and after a time tend to disappear ; 
and accompanying these changes we find the evidences of old exudations of 
blood along the vessels, with fatty disintegration, and the appearance of cor- 
pora amylacea among the diseased tissue. The process is a progressive one ; 
and it is almost needless to say that in the changes occurring in the gray 
matter of the hemispheres we have an ample explanation alike of the mental 
excitement leading on to dementia, and of the paretic trembling going on to 
more or less complete muscular paralysis, which in association characterizes 
the disease. It is obvious, too, to those who are at all acquainted with these 
affections, that there is a clinical relationship between general paralysis 
on the one hand, and tabes dorsalis, disseminated sclerosis, and bulbar 
paralysis on the other ; and that many of the paralytic symptoms ot 
general paralysis resemble those of one or other of these affections, and, at 
any rate, may in some cases be referred to concurrent sclerosis of the cord, 
medulla, and other parts of the central nervous organs. 
66 



1042 



DISEASES OF THE NERVOUS SYSTEM. 



In most cases of idiocy, excepting those due to early epilepsy, to severe 
mental shocks and other functional conditions operating after birth, there is 
ample explanation in the anatomical character of the skull and brain of 
the mental feebleness which is present. In some cases the brain, and con- 
sequently the skull, are unusually, and it may be, very remarkably small. 
In many cases the brain is imperfectly developed — the corpus collosum, or 
some other important part of it, is incomplete or absent ; the posterior 
lobes do not cover the cerebellum ; one side or part of the brain or cere- 
bellum is atrophied ; or the convolutions are few in number and soft, as 
in some of the lower animals. Sometimes the child is born with congeni- 
tal hydrocephalus, or a portion of the brain, or an offset of its membranes, 
protrudes through a hole in the parietes of the skull. In some instances, 
as in cretinism, the idiocy appears to depend primarily on premature ossi- 
fication of the bones at the base of the skull, and consequent interference 
with the due development of the brain. Sclerosis is frequently met with. 
Occasionally undue enlargement of the brain, without other visible change, 
has been observed in idiots. And it must be added that even in cases of 
congenital idiocy it sometimes happens that no apparent defect of the 
central nervous organs or of their envelopes has been detected. 

Treatment — We shall not discuss the treatment of insanity at any length, 
partly because the object we set before ourselves in treating of insanity 
was mainly pathological and to aid diagnosis, and partly because it so 
largely consists in the moral restraint which a well-ordered asylum affords. 
This subject may be considered under two heads, namely, the moral and 
the therapeutical. 

(a) Of these the moral treatment is by far the most important. It is 
obvious that, putting out of the question our duties to the lunatic's friends 
and to the public, it is for his own benefit that we should protect him from 
the consequences of his violence or folly ; and that just as it is salutary to 
restrain a wayward child, or a sane man's ungovernable temper, so it is 
salutary to the madman to put a check upon his caprices or his passions. 
It is from another point of view important that maniacs who are in any 
way dangerous or mischievous should be restrained from yielding to their 
insane instincts or impulses. Our first object in fact in the treatment of 
insanity should be to remove the patient from those surroundings and as- 
sociations in the midst of which his insanity arose. How this shall be 
best effected must depend on the nature of the case, and on the pecuniary 
circumstances and social position of the patient. But in all cases this re- 
moval should be accompanied by restraint. In some cases the patient, 
with a suitable attendant or keeper, may be allowed to travel. Change of 
scene, change of associations, the moral pressure which is brought to bear 
upon him, and the inability under which he now labors of giving play to 
his insane impulses and actions, are valuable items of his treatment, and 
collectively often effect a cure. In some cases, where travelling is for any 
reason undesirable, or is forbidden by pecuniary considerations, removal 
in company of a skilled attendant to some country-house, or sea-side place 
is indicated. The cases which are best treated in either of these ways are 
those of the several forms of insanity in their early stages, and those cases 
in which insanity has been caused, or is kept up by indulgence in masturba- 
tion, drunkenness, or other vicious habits. Hysterical cases also are gener- 
ally best treated away from asylums. The cases for which private treat- 
ment is specially unsuitable, are those of violent mania, those of melan- 
cholia, with suicidal or murderous propensities, those in which the patient 



INSANITY. 



1043 



persistently refuses food, and those in which the association with epilepsy 
tends to provoke sudden explosions of dangerous delirium. For most 
lunatics, no doubt, an asylum is the most suitable means of restraint and 
treatment. For many, because the cost of providing for their separate 
care is beyond the means of those who are responsible for them ; and for 
most, because from the special characters of their malady they are best 
and safest treated in association with other patients, and under the rules 
and regulations of a well-ordered establishment. It is, no doubt, true that 
many patients resent their incarceration, and experience a real grief and 
pain in being separated from their friends, and put into the society of 
others like themselves ' r but as a matter of fact, the creation of a real 
cause of emotion, by taking the patient out of his unsubstantial sorrows, 
is not infrequently of benefit to him ; and, on the other hand, it is astonish- 
ing how soon such patients reconcile themselves to their altered circum- 
stances. Many lunatics accept their new position as a matter of course, 
and without any evidence of mental suffering being awakened by it. The 
advantages of an asylum are obvious. The patient is deprived of the power 
of tyrannizing over the members of his household, or those who are 
subordinate to him ; he cannot spend money lavishly, or speculate, or in- 
dulge in debauchery, or commit acts of violence on himself or others ; he 
is spared the irritating opposition or weak submission to his will of those 
about him ; he is fed regularly and wholesomely, and compelled to keep 
good hours ; the obvious madness of some of his companions not improb- 
ably impresses him, and the recognition of their condition may even have a 
beneficial effect upon his own. Moreover, patients in asylums are, accord- 
ing to their condition and tastes, encouraged to spend their time in a mix- 
ture of work and recreation which has been carefully thought out and pre- 
pared for them. Further, there is usually an ascending scale of treatment, in 
virtue of which patients as they improve, receive more indulgence, and are 
regarded more and more as sane persons. In asylums, again, the facilities 
for treating troublesome and violent patients are much greater than they 
are at lodgings or even at home. It may be added that it is not generally 
wise to irritate patients by opposition ; or even to argue with monomaniacs 
on the subject of their delusions. At the same time it is well that they 
should see that you do not acquiesce in them. In the above remarks it is 
assumed that the cases under treatment are curable. For incurable patients, 
especially those suffering from chronic mania, dementia, or general paraly- 
sis, and for many idiots, an asylum is clearly the most appropriate place 
of residence. 

(b) The therapeutical treatment of insanity, on the whole, is of little 
special value. In insanity, as in other cases, possibly even more than in 
other cases, it is of course important to treat any bodily affection which 
may be present. Lunatics are not infrequently feeble and anaemic. Un- 
der such circumstances iron and quinine or other tonics with good diet are 
clearly called for. Tuberculosis, pneumonia, pleurisy, and other diseases 
are very apt to arise in the course of insanity, and to give but few indi- 
cations of their presence. It is needless to say that such maladies ought 
not to be overlooked, and that they demand special treatment. If the 
stomach or bowels be deranged, if gout or rheumatism be present, if there 
be uterine or ovarian disorder, if pains or aches be complained of, these 
several affections should be attended to. And, again, if the patient's in- 
sanity have arisen from drink, or if self-abuse be at the bottom of his 
malady, special therapeutic treatment will probably be desirable. 



1014 



DISEASES OF THE NERVOUS SYSTEM. 



Many systems of treatment of insanity have been advocated at different 
times. Blood-letting, hot and cold baths, counter-irritation, purging, and 
the use of various narcotics, comprise the chief of those to which recourse 
has been had ; and each of these has on different occasions been largely 
pushed, and greatly lauded. At the present time none of these is re- 
garded as of specific value ; and they are severally used in moderation only 
as occasion requires. 

General blood-letting has fallen into disuse ; but occasionally the appli- 
cation of the cupping glasses or of leeches for the relief of cerebral con- 
gestion seems to be useful. Even this modified form of blood-letting, 
however, is seldom employed. 

Baths, no doubt, are important agents. Warm baths, continued for 
some hours, are often useful in calming excitement. Cold baths and shower- 
baths, applied for not more than a minute or two at a time, are frequently 
beneficial in the treatment both of melancholia and of mania. Cold to 
the head, combined with the immersion of the body in a warm bath, is 
a specially valuable method of reducing excitement and promoting sleep. 

Counter-irritants to the head or nape of the neck, more especially to the 
former, are said to be of service mainly in chronic cases. 

Active systematic purging has almost fallen into desuetude. It is im- 
portant, however, and necessary in many cases, to keep the bowels regulated. 

Narcotics are indispensable in the treatment of insanity ; but they 
should not be recklessly employed, for they are capable of much harm as 
well as of much benefit. Of these, opium is by far the most valuable. 
The cases in which it is specially serviceable, are those of commencing in- 
sanity, when the patient is sleepless and irritable and hyperjesthetic ; those 
in which mania is subsiding ; melancholic cases ; and cases of insanity due 
to alcoholism or exhaustion. Among other narcotics or sedatives which 
are, or have been, employed must be enumerated : chloral hydrate, hyos- 
cyamus, conium, digitalis, and bromide of potassium. The bromide of 
potassium is frequently given in combination with one of the others, and 
appears often to be of service. To narcotics generally, with the exception 
of opium, at any rate to narcotics habitually given, Dr. Maudsley enter- 
tains serious objections. 

In conclusion, when insane patients refuse food it becomes necessary to 
feed them periodically by means of the stomach-pump ; and it may be 
added that chronic insanity of whatever kind, rarely calls for medicinal 
treatment, excepting for the relief of accidental complications. 



INDEX. 



ABDOMEN, examination of, 578 
by auscultation, 581 
by inspection, 579 
by palpation, 579 
by percussion, 581 
regions of, 578 
Abdominal dropsy (see Ascites), 655 
lymphatic glands, tubercle of, 615 
phthisis, 614 

typhus (see Enteric Fever), 210 

Abortion in relapsing fever, 192 
in syphilis, 246 

Abscess, 65 

of brain (see Encephalitis), 877 
of heart (see Myocarditis), 463 
of kidney (see Pyelitis and Nephritis, 

circumscribed), 736, 739 
of liver (see Hepatitis acute), 682 
of lungs (see Pneumonia), 371 
of pancreas, 716 
of spleen, 521 

retro-pharyngeal (see Retro-pharyngeal 
Abscess), 569 
Abstinence, as cause of disease, 39. 
Acarus folliculorum, 321 

scabiei, 317 
Achorion Schoenleinii, 323 
Acne, 303 

causation of, 303 

description of, 303 

indurata, 304 

punctata, 304 

rosacea, 305 

simplex, 304 

treatment of, 305 
Active congestion, 108 

Acute (see Inflammation and different dis- 
eases). 

Addison, T., on vitiligoidea, 309 

Addison, W., on migration of leucocytes, 52 

Addison's disease, 515 

causation of, 516 

definition of, 515 

morbid anatomy of, and pathology 
of, 516 

symptoms and progress of, 517 
treatment of, 518 
keloid, 311 
Adenia, 530 
Adenoid cancer, 95 
of bowels, 621 
of liver, 696 
iEgophony, 351 
jEtiology, or causation, 36 

(See also different diseases.) 
Age, as a cause of disease, 37 



Ague, 263 

brow, 269 

cachexia in, 270 

causation of, 263 

chronic, 270 

cold stage of, 265 

death in, 269 

definition of, 263 

diagnosis of, 268 

duration of, 269 

enlargement of, liver in, 271 
spleen in, 268, 271 

history of, 263 

hot stage of, 266 

incubation of, 265 

intermissions in, 266 

intermittent form of, 265 

malarious origin of, 263 

morbid anatomy of, 270 

non-contagiousness of, 263 

paroxysms of, 267 

pathology of, 270 

pigment-formation in, 271 

quartan, 267 

quotidian, 267 

remittent form of, 267 

sweating stage of, 266 

symptoms and progress of, 265 

tertian, 267 

treatment of, 271 

unusual form of, 268 
Air, impure, as cause of disease, 41 

passages, affection of, in diphtheria, 
204 

in syphilis, 242, 244 
casts of, 365 

in the pleura (see Pneumothorax), 424 
Albumen in urine, 728 

tests for, 728 
Albuminoid degeneration (see Lardaceous 

Degeneration), 97 
Albuminuria in diphtheria, 206 
■ in scarlet fever, 166 

(See also different renal diseases) 
Alcoholic poisoning, chronic, 545 
Alibert on keloid, 308 

on lupus erythematosus, 307 
on pemphigus, 301 
Alimentary canal, affection of, in hysteria, 
971 

Alimentation in health, 49 

Allbutt, on hypertrophy of heart, 447 

Alopecia areata (vel circumscripta), 325 

causation of, 325 

description of, 325 

treatment of, 327 



1046 



INDEX. 



Althaus, on electrolytic treatment of hyda- 
tid cysts, 701 

on lead poisoning, 551 
Amaurosis in Hsematemesis, 660 
Amnesia, 851, 853 
Amphoric breathing, 348 

bubble, 353 
Amyloid degeneration (see Lardaceous), 97 
Amyotrophies spinales deuteropathiques 

(see Lateral Sclerosis), 892 
Antemia (idiopathic), 531 

causation of, 532 

definition of, 53 L 

lymphatica, 531 

of brain, 982 

symptoms of, 981 
treatment of, 984 

pathology of, 534 

pernicious, 533 

progressive pernicious, 533 

symptoms and progress of, 532 

treatment of, 535 
Aneemic dropsy, 111 
Anaesthesia, 838 

bulbar, 839 

cerebral. 838 

general, 838 

in chorea, 947 

in hysteria, 969 

of nerves, 840 

spinal, 839 

unilateral, 838 
(See a Iso various nervous diseases) 
Anasarca, 109 

in heart disease, 447 

in renal diseases, 735 

in scarlet fever, 165 
Andral on tubercle of nervous centres. 917 
Aneurism, 488 

causation of, 4S9 

contents of, 490 

definition of, 488 

effects of, on parts around, 491 

form and size of, 489 

morbid anatomy of, 489 

results of, 491 

symptoms and progress of, 491 
treatment of, 492 
wails of, 490 
Aneurisms, abdominal, 497 

morbid anatomy of, 497 
symptoms of, 497 
treatment of, 498 
cerebral (see Morbid Growths), 916, 920 

miliary. 927 
of heart, 473 

causation of, 473 
morbid anatomy of, 474 
symptoms of, 474 
thoracic, 493 

morbid anatomy of, 493 
symptoms of, 493 
treatment of, 497 
Angina pectoris, 480 

causation of, 480 
pathology of, 480 
symptoms and progress, 480 
treatment of, 482 
Angioma, 78 

cavernous, 78 



Angioma, simple, 78 
Ankle clonus, 837 
Anstie, on delirium tremens', 549 
on neuralgia, 1004 
on urea, in urine in pneumonia, 115 
Anthrax, or splenic fever, 141, 142 
Anthrax (see Carbuncle), 282 
Aorta, aneurism of (see Aneurisms, Thora- 
cic, and Abdominal), 493, 497 
Aortic valve disease, diagnosis of, 452 
effects of, on heart, 445 
obstructive, 443 
prognosis of, 456 
regui'gitant, 443 
treatment of, 457 
Aphasia, 851 

in megrim, 988 

in obstruction of cerebral arteries, 938 
Aphemia, 851, 852 
Aphonia, 331 

clericorum, 361 
hysterical, 970 
Aphthae (see Thrush), 560 
Apnoea, death from, 125 
Apoplectiform attacks in disseminated 

sclerosis, 909 
Apoplexy (see Cerebral Ansemia and Conges- 
tion), 983 
(see Cerebral Hemorrhage) 926 
(See also Morbid Growths, Sunstroke, 

and other affections of the Brain) 
pulmonary (see Hemorrhage of Respi- 
ratory organs), 421 
Arteries, degeneration of, 487 
causation of, 487 
morbid anatomy of, 487 
symptoms of, 487 
cerebral, obstruction of (see Cerebral 

Arteries, Obstruction of), 935 
dilatation of (see Aneurism), 488 
diseases of, 485 et seq. 
embolism of (see Embolism), 500 
obstruction of, 501 
pulmonic, embolism of, 505 

thrombosis of, 505 
systemic embolism of, 506 

thrombosis of, 506 
syphilitic disease of, 245 (See also Ar- 
teritis), 485 
thrombosis of (see Thrombosis), 500 
Arteritis (see peri- and endo- arteritis). 485, 
486 

Arthritis deformans (see Rheumatoid Ar- 
thritis), 791 

rheumatoid, 791 
Ascaris lumbricoides (see Round Worm, 

Common), 632 
Ascites, 655 

causation of, 655 

morbid anatomy of, 655 

symptoms and progress of, 656 

treatment of, 657 
Asiatic cholera (see Epidemic Cholera), 222 
Asphyxia, death from, 125 
Asthenia, death from, 124 
Asthma, 428 

causation of, 428 

definition of, 428 

pathology of, 430 

symptoms and progress of, 428 



INDEX 



1047 



Asthma, treatment of, 431 
Ataxy, locomotor (see Tabes Dorsal is), 896 
Atelectasis pulmonum (see Pulmonary Col- 
lapse), 419 
Athetosis, 841 
Atrophy, 95 

of heart, 442 

of kidney {see Hydronephrosis), 760 
of spleen, 523 

progressive muscular {see Muscular 
Atrophy, Progressive), 889 

yellow, of liver (see Malignant Jaun- 
dice), 713 
Aura, epileptica, 953 

Aural vertigo (see Meniere's Disease), 989 
Auscultation, 339, 344, 581 

abnormal, 347 

normal, 345 



BACILLI anthracis in splenic fever, 142 
Bacteria in diphtheria, 208 
in erysipelas, 279 
in gangrene, 103 
in pyaemia, 253 
in urine, 732 
septic, 143 

Badcock, on identity of cowpox and variola, 
176 

Bakers' itch, 294 
Baldness in syphilis, 241 
Balfour on haemic murmurs, 455 
Baly on dysentery, 603 
Bancroft on filaria, 637 
Barbadoes leg (see Elephantiasis), 313 
Barker, T. A., on auscultation, 353 
Barlow on urine in abdominal obstructions, 
652 

Barthez and Rilliet on noma, 563 

Basedow's (see Graves's) disease, 477 

Bastian, on aphemia. 852 

Baths in the treatment of insanity, 1044 

Bazin on alopecia areata, 327 

Beale on contagium, 142 

on molluscuin contagiosum, 315 
Bed-sores in nervous diseases, 847 
Bell's paralysis (see Portio Dura, Paralysis 
of), 996 

Bennett, Hughes, on leucocythaemia, 82 
Bernard on death from high temperature, 
118 

on cause of diabetes insipidus, 772 
on pathology of diabetes, 769 
Betz on anatomy of brain, 814, 823 
Bichat on causes of death, 124 
Bile, composition of, 676 

ducts, obstruction of (see Hepatic Ducts, 
etc.), 708 
Bilharzia haematobia, 755 
Biliary concretions (see Gall Stones), 705 
Bird, Golding, on uric acid calculi, 759 
Black induration of lung, 387 
vomit in yellow fever, 196 
Blackley, on hay-asthma, 432 
Bladder, gall, affections of. 710 
Bladder, urinary, dilatation of, 775 
diseases of, 774 
inflammation of, 774 
morbid growths of, 775 
tubercle of, 775 



Blebs, meaning of term, 276 
Bleeder disease, 540 
Blood, diseases of, 508 et seq. 
in urine, 728 

detection of, 729 
(see Haeinaturia), 764 
Blo^d-letting in the treatment of insanity, 
1044 

Bloodvessels in renal disease, 734 
Boeck on inoculation of syphilis, 248 
Boil, 282 

Bone-affections in leprosy, 262 
in mollities ossium, 808 
in pyaemia, 251 
in rickets, 804 
in syphilis, 242, 244 
Bothriocephalus latus. account of, 628 
symptoms of, 628 
treatment of, 629 
Bouchard on cerebral aneurisms, 927 
Bouchut on nitrate of silver in pertussis, 
153 

Bovvditch on causation of tubercle, 389 

on paracentesis thoracis, 384 
Bowels, adenoid cancer of, 621 

cirrhosis of, 614 

morbid anatomy of, 614 
symptoms of, 614 

colloid cancer of, 620 

compression and traction of, 644 

con-tipation of,. 641 

degenerations of, 638 

encephaloid cancer of, 620 

epithelioma of, 621 

hemorrhage from (see Hemorrhage from 

Stomach and Bowels), 658 
impaction of foreign bodies in, 646 
inflammation of (>-ee Enteritis), 585 
internal strangulation of, 645 
intussusception of, 648 
lymphadenoiua of, 621 
malignant tumors of, morbid anatomy 
of, 619 

symptoms of, 622 

treatment of, 625 
non-malignant tumors of, 618 
obstruction of, 640 et seq. 

constipation in, 651 

duration of life in, 652 

pain in, 651 

statistics of, 652 

treatment of, 653 

tumor in, 652 

urine in, 652 

vomiting in, 651 
polypi of, 618 
sarcoma of, 621 
scirrhus of, 619 
stricture of, 641 
torsion or twisting of, 644 
tubercle of, 614 

morbid anatomy of, 614 

symptoms and progress of, 616 

treatment of, 618 
ulceration of, 593 

causation of, 593 

consequences of, 596 

morbid anatomy of, 593 

symptoms and progress of, 596 

treatment of, 597 



Bowels, ulceration of, varieties of, 594 
villous growths of, 618 

Brain, abscess of (see Encephalitis), 876 

anaemia of (see Anaemia of Brain), 982 
congestion of (see Congestion of Brain), 
982 

diseases of, 860 et seq. 
dropsy of, 939 

hemorrhage of (see Cerebral Hemor- 
rhage), 926 
hydatids of, 919 

inflammation of (see Encephalitis), 876 
morbid growths of (see Morbid Growths 

of Brain), 916 
pyaemic affection of, 251 
softening of (see Cerebral Arteries, ob- 
struction of), 935 
syphilitic affection of, 245, 917, 921 
tubercle of, 868, 916 
Breast, affection of, in hysteria, 972 

in mumps, 154 
Bretonneau on diphtheria, 201, 209 

on dysentery, 607 
Briancon, on hydatid thrill, 699 
Bright, R., on case of Cardinal, 941 

on malignant jaundice, 7l4 
Bright's disease, acute, 740 

causation of, 740 \ 

morbid anatomy of, 740 

symptoms and progress of, 742 

treatment of, 743 

varieties of, 741 
chronic, 744 

(interstitial), 746 

causation of, 746 

morbid anatomy of, 746 

treatment of, 750 

(parenchymatous), 744 

causation of, 744 

morbid anatomy of, 744 

symptoms and progress of, 745 

treatment of, 750 
Brinton on gastric ulcer, 592 

on impaction of gall stones, 648 

on intussusception, 649 

on statistics of intestinal obstruction, 

642 

on stricture of bowel, 642, 643 
on variations of urine in intestinal ob- 
struction, 652 
Broadbent on hemiplegia, 832. 842 
Broca on aphasia, 852, 855 
Broca's convolution, 812, 824 
Brodowsky on giant-cells, 84 
Bromide of ammonium in rheumatism, 790 
Bronchial breathing, 347 

tubes, congestion of, 417 

dilatation of (see Bronchiectasis), 410 
diphtheritic affection of, 204 
inflammation of (see. Bronchitis), 361 
spasm of (see Asthma), 427 
syphilitic affection of (see Syphilitic 
Disease of), 402 
Bronchiectasis, 410 
causation of, 410 
morbid anatomy of, 410 
symptoms and progress of, 412 
treatment of, 412 
varieties of, 410 
Bronchitis, 361 



Bronchitis, acute. 363 

bronchorrhoea in, 365 
capillary, 364 
causation of 361 
chronic, 364 
dry, 365 

morbid anatomy of, 361 
plastic, 366 

symptoms and progress of, 363 

treatment of, 366 
Bronchocele (see Goitre), 508 
Bronchophony, 347, 350 
Bronchorrhoea, 365 
Bronzed skin (see Addison's Disease), 515 
Brown, Crichton. on treatment of epileptic 

paroxysm, 961 
Brown induration of lung, 387 
Brown- Sequard on epileptic convulsions in 
guinea-pigs, 960 

on paralysis of portio dura, 998 

on reflex phenomena, 849 

on spinal epilepsy, 909 
Bruit, cardiac (see Murmur), 449 

d'airain, 349 

de diable, 532 

de pot fele, 344 
Buboes in plague, 189 
Buchanan, on causation of phthisis, 389 
Budd, G- , on gastric ulcer, 592 
on hepatic abscess, 686 
on pyaemia in dysentery, 604 
on pyrosis, 664 

W., on origin of enteric fever, 212 
Bulama boil, 321 
Bulbar anaesthesia, 839 

paralysis, 832 
Bullae, meaning of term, 276 

Willan's fourth order, 276 
Burq on metallo-therapeutics, 975 
Burton on blue line in lead-poisoning, 551 



pACIIEXIA (see Dyscrasia), 56 
' > Caecum, ulceration of (s^e Typhlitis), 599 
Calcareous degeneration, 100 
Calculi, biliary (see Gall-stones), 704 
pancreatic, 715 

urinary (see Urinary Concretions), 732, 
757 

Calenture (see Sunstroke), 984 
Cancer (see Carcinoma), 91 
Cancroid (see Epithelioma), 94 
Capillary bronchitis, 364 
Carbuncle (boil), 282 

causation of, 283 

definition of, 282 

in plague, 189 

morbid anatomy of, 283 

symptoms of, 284 

treatment of, 284 
Carcinoma, 91 

adenoid or tubular, 95 

colloid, 93 

encephaloid, 92 

epithelial, 94 

erectile or haematoid, 93 

lipomatous, 93 

melanotic, 93 

pultaceous, 93 

scirrhus, 92 



INDEX. 



1049 



Carcinoma. {See a ho Morbid Growths, Tu- 
mors, and different organs ) 
Cardiac diseases {see Heart, Diseases of), 
434 et seq. 

dropsy, 109 
Caries of vertebrae, 864 
Carter, V., on chyluria, 763 

on leprosy, 262 
Cartilaginous tumors, 75 
Caseation, 99 
Casts of air- passages, 335 

urinary tubules, 729 

blood, 730 

epithelial, 730 

fatty, 730 

granular, 730 

hyaline, 730 

mucous, 730 

waxy, 730 
Catalepsy, 975, 976 

treatment of, 977 
Catarrh, 557 

autumnal, 432 

causes of, 557 

epidemic {see Influenza), 146 
morbid anatomy of, 557 
symptoms and progress of, 557 
treatment of, 559 
Causation of disease {see ^Etiology), 36 

{See also different diseases) 
Causes of disease, chemical, 43 
endopathic, 44 
exciting, 36, 42 
exopathic, 43 
mechanical, 43 
predisposing, 36, 37 
proximate, 36 
vital, 44 
fever, specific, 137 
Cavernous breathing, 349 

tumors of liver, 694 
Cavities, pulmonary, detection of, 354 
Ceely on identity of cow-pox and variola, 
176 

Cell-districts, 48 

Cerebral anaemia {see Anaemia of Brain), 
981 

anaesthesia, 838 

arteries, obstructions of, 935 
aphasia in, 938 
bed-sores in, 937 
causation of, 935 
hemianaesthesia in, 937 
hemiplegia in, 938 
morbid anatomy of, 935 
symptoms and progress of, 936 
treatment of, 939 

congestion {see Congestion of Brain), 
981 

dropsy {see Hydrocephalus), 939 
functions (localization of), 821 
hemorrhage, 926 

bed-sores in, 933, 

causation of, 926 

coma in, 930 

hemianaesthesia in, 932 

hemiplegia in, 930 

morbid anatomy of, 926 

muscular rigidity in, 933 

paralysis in, 930 



Cerebral hemorrhage, recurrence of attacks 
of, 933 

symptoms and progress of, 929 
treatment of, 934 
paralysis {see also Hemiplegia), 831 
Cerebro spinal fever, 198 
causation of, 198 
causes of death in, 199 
complications of, 199 
definition of, 198 
history of, 198 
meningitis in, 199 
morbid anatomy of, 200 
mortality of, 200 
symptoms and progress of, 198 
treatment of, 200 
meningitis, epidemic {see Cerebro-spinal 

Fever), 199 
system, influence of diseases of, in 
causing bed-sores, 847 
eruptions in, 845 
over-nutrition, 844 
of bones, 845 
of joints, 845 
of muscles, 844 
of skin, 845 
of viscera, 848 
Cestoda, general account of. 626 
Chalk-stones {see Grout), 793 
Chancre, Hunterian, 240 
Charcot on affection of lateral columns of 
cord, 834 

on affection of posterior columns of 
cord, 833 

on artery of cerebral hemorrhage, 
830 

on cerebral hemorrhage, 928 

on cerebral miliary aneurisms, 927 

on decussation of optic tracts, 826 

on disseminated sclerosis, 905 et seq. 

on hypertrophic cirrhosis, 689 

on hysteria, 968 et seq. 

on infantile spinal paralysis, 885 

on inflammation of nerve-cells, 883 

on lateral sclerosis, 892 et seq. 

on locomotor ataxy, 897 et seq. 

on nutritive lesions in nervous diseases, 
845 et seq. 

on paralysis agitans 911 et seq. 

on spinal hemorrhage, 878 

on spinal paralysis in adults, 887 

on tubercle, 86, 87 
Charles on myxoedema, 515 
Chauveux, on contagion of cow-pox, 141 

on inoculation with putrid fluids, 57 

on inoculation of smallpox on lower 
animals, 176 {note) 
Chemical causes of disease, 43 
Chest, contraction of, in disease, 338 

expansion of, in disease, 337 

form of, in disease, 337 

movement of, in disease, 338 

regions of, 330 
Cheyne, on hoarseness in children, 358 
Chicken-pox, 180 

causation of, 180 

definition of, 180 

duration of, 181 

incubation of, 181 

symptoms and progress of, 181 



1050 



INDEX. 



Chicken pox. treatment of, 181 
Chilblain, 286 

Chloasma (see Tinea Versicolor), 325 
Chloral in ozsena, 570 
Chlorosis [see Anasmia), 531 
Cholera, English, 670 

epidemic {see Epidemic Cholera), 222 

fungus (Hallier's), 223 

'infantum, 671-673 

summer, 670 
Chondroma, 54 
Chorea, 945 

anaesthesia in, 948 

and heart disease, connection between, 
945 

and rheumatism, connection between, 
945 

causation of, 945 
definition of, 945 
emotional sensibility in, 948 
imbecility in, 948 
morbid anatomy of, 949 
paralysis in, 948 
pathology of, 949 
symptoms and progress of, 945 
terminations of, 948 
treatment of, 950 
Christison, on diagnosis of tetanus, 980 
Chronic (refer to different diseases and in- 
flammations) 
Chylous urine (see Chyluria), 762 
Chyluria, 762 

causation of. 762 
pathology of, 763 
symptoms of, 762 
treatment of, 763 
Cicatrization, 68 
Circulation in health, 49 
Cirrhosispf bowels, 614 

symptoms of, 614 
of liver 687 
atrophic, 687 

causation of, 687 
morbid anatomy of, 687 
symptoms and progress of, 688 
treatment of, 690 
hypertrophic, 689 

causation of, 689 
morbid anatomy of, 689 
symptoms and progress of, 689 
treatment of, 690 
syphilids, 690 
of lungs, 385 

black induration in, 387 
brown induration in, 387 
causation of, 335 
definition of, 385 
gray induration in, 387 
in miners and others, 387 
morbid anatomy of, 385 
red induration in, 387 
symptoms of, 387 
treatment of, 388 
of stomach, 614 

symptoms of, 614 
Clarke, Lockhart, on anatomy of cord, 816 
on sclerosis, 883 
on tetanus, 980 
Clavus in hysteria, 968 
Climate as cause of disease, 40 



Clonic spasms, 841 
Cloudy swelling, 95 
Coats on hydrophobia, 235 
Cobbold on filaria (note), 636 

on trichina spiralis, 634 
Cohnheim on inoculation of tubercle, 87 

on inflammation of cornea, 61 

on migration of leucocytes, 52 
Coindet on use of iodine in goitre, 511 
Cold as cause of disease, 41 

(see Catarrh) , 557 
Colic, hepatic, 706 

lead (see Lead-poisoning), 550, 551 
Colica pictonum (see Lead-poisoning), 550, 
551 

Colin on blood in glanders, 237 
Collapse, 122 

circulation in, 123 

in cholera, 226 

of lungs (see Pulmonary Collapse), 419 
of lungs, in diphtheria, 208 
nervous functions in, 123 
symptoms of, 122 
temperature in, 123 
Collier's phthisis, 387 
Colloid cancer, 93 

degeneration, 96 , 
Colon, inflammation of (see Dysentery), 602 

ulceration of (see Dysentery), 602 
Coloring matters in urine, 722 
Coma, death from, 127 
Compression of bowels, 644 
causation of, 644 
morbid anatomy of, 644 
symptoms and progress of, 644 
treatment of, 651 
Concretions, biliary (see Gall stones), 704 
pancreatic, 715 

urinary (see Urinary Concretions), 732, 
757 

Congestion, active and passive, 108 
of brain, 981 

symptoms of, 981 

treatment of, 984 
of kidney, 751 

causation of, 751 

morbid anatomy of, 751 

symptoms of, 651 

treatment of, 751 
of larynx, trachea, and bronchial tubes, 

417 
of liver, 691 

causation of. 691 

morbid anatomy of, 691 

symptoms and progress of, 692 

treatment of, 693 
of lungs, 417 

causation of, 41 7 

morbid anatomy of, 417 

symptoms of, 417 

treatment of, 417 
of pancreas, 715 
of respiratory organs, 417 
of spleen (see Spleen, Congestion of), 
519 

Connective tissue, 47 

tumors, 73 
Consolidated lung, detection of, 354 
Constipation, 641 

causation of, 641 



INDEX 



1051 



Constipation, morbid anatomy of, 641 
symptoms of, 641 
treatment of, 653 

Constitution, epidemic, 41 

Contagia, 138 

action of, within organism, 138 
are vegetable organisms, 142 
• as causes of disease, 44 
behavior of, external to body, 140 
Chauveau and Sanderson's experiments 
on, 141 

discharge of, from system, 140 

with subsequent protection, 140 

mode of entrance of, into organism, 140 
into organism, by atmosphere, 
138 

into organism, by food, 139 
into organism, by inoculation, 
139 

multiplication of, in organism, 139 

nature of, 140 
Contagion in relation to fevers, 138 
Contagious diseases, management of, 144 
Contractility, galvanic and Faradic, 835, 
857 et seq. 

Contraction of limbs in disseminated scle- 
rosis, 908 
Convulsions, 840 

choreic, 840 

clonic, 840 

in chorea, 946 

in epilepsy, 953 

infantile {see Infantile Convulsions), 963 
in hooping-cough, 151 
in hysteria, 967 

in morbid growths of brain, 922 
tonic, 841 
varieties of, 840 
Cord, spinal, dropsy of {see Hydrorrhachis), 
939, 942 

hemorrhage of {see Spinal Hemor- 
rhage), 926, 929 
inflammation of {see Meningitis and 

Myelitis), 868, 876 
morbid growths of {see Morbid 

Growths of Spinal Cord), 916 
sclerosis of {see Sclerosis), 882 et seq. 
Cornil and Ranvier on carcinoma, 91 

on classification of tumors, 73 

on cloudy swelling, 96 

on epithelioma, 95 

on psammoma, 90 

on pultaceous cancer, 93 

on rheumatism, 784 

on rickets, 802 

on syphilitic disease of liver, 690 
on tubercle, 84 
Coronary arteries of heart, degeneration of, 
473 

Corona veneris, 241 

Corrigan, on water-hammer pulse, 453 

Cough, 333 

varieties of, 333 
Counter-irritants in the treatment of in- 
sanity, 1044 
Coup de soleil (see Sunstroke), 984 
Cow-pox {see also Vaccination), 175 

Badcock's experiments, 176 

causation of, 175 

Ceely's experiments, 176 



Cow-pox, Chauveau's experiments {note), 176 
definition of, 175 
relations of, with smallpox, 175 
symptoms and progress of, in cattle, 
176 

symptoms and progress of, in man, 176 
Cracked-pot sound, 344 
Cramps in cholera, 227 
Craniotabes, 806 

Creighton, on vacuolation, Ac , of liver- 
cells (note), 60 
Crepitation, 352 
Cretinism, 512 

treatment of, 514 
Croup, membranous {see Diphtheria), 200 

spasmodic, 358, 360 
Cry, epileptic, 953 

hydrocephalic, 871 
Curling, on thyroid body, 513 
Cutaneous diseases, 274 et seq. 
Cyanosis, 482 

causation of, 482 

pathology of, 483 

symptoms and progress of, 482 
Cyrtometer, 339 

Cyst-worms, general account of, 626 
Cysticercus cellulosae, 627 

of brain and cord {see Morbid 

Growths), 916, 919 
of heart, 470 
symptoms of, 628 
treatment of, 629 
tsenias mediocanellatee, 628 
symptoms of, 628 
treatment of, 629 
Cystine, 724 

calculi, 733 
Cystitis (see Urinary Bladder, Inflammation 

of), 774 
Cysts, 105 

by dilatation, 105 
by extravasation, 106 
by retention, 106 
by softening, 107 
of Fallopian tubes, 778 

symptoms and progress of, 780 
treatment of, 781 
of kidney, 746 
of liver, 694 
of ovary, 778 
of pancreas, 716 
of spleen, 523 



DANDY FEVER (see Dengue), 193 
Danielssen and Boeck on leprosy, 260, 
262 

Davies, H., on blisters in rheumatism, 789 
Davy on temperature, 112 
Death, 124 

from failure of circulation, 125 
of elimination, 126 
of nervous system, 127 
of nutrition, 124 
of tissues {see Necrosis), 101 
Decay in health, 50 
Degeneration, 95 
calcareous, 100 
caseous, 99 
colloid. 96 



1052 



INDEX. 



Degeneration, fatty, 98 
in health, 50 
lardaceous, 97 

of kidney, 756 

of liver, 703 

of spleen, 524 
mucous, 96 

of arteries (see Arteries, Degeneration 

of), 487 
of bowels, 638 

of coronary arteries of heart, 473 
of heart (see Heart, Degeneration of), 
470 

of stomach, 638 

of valves of heart (see Valves of Heart, 

Degeneration of), 472 
pigmentary, 99 
uratic, 100 
Delafond on filaria, 637 
Delaroche and Berger on death from heat, 
117 

Delirium, 856 

tremens, 545, 1011, 1028 
causation of, 546 
morbid anatomy of, 548 
pathology of, 548 
symptoms of, 546 
treatment of, 549 
Deltoid rheumatism, 1000 
treatment of, 1000 
Dementia, 1030 
Demodex folliculorum, 321 
Dengue, 193 

causation of, 193 
definition of, 193 
diagnosis of, 194 
history of, 193 

symptoms and progress of, 193 
treatment of, 194 
Dentition, inflammation of gums in, 564 
Derangement, functional, 103, 107 

mechanical, 103, 104 
Development in health, 49 
Dextrose in urine, 725 
Diabetes, 766 

causation of, 766 
morbid anatomy of, 769 
pathology of, 769 
symptoms and progress of, 766 
treatment of, 770 
insipidus, 772 
causation of, 772 
definition of, 772 
morbid anatomy of, 772 
symptoms and progress of, 772 
treatment of, 772 
ergot in, 772 
tannic acid in, 772 
Diarrhoea, 668 

causation of, 668 
infantile, 670 
pathology of, 668 
premonitory, of cholera, 226 
raw meat in, 673 
symptoms and progress of, 669 
treatment of, 671 
Dickinson on acute Bright's disease, 743 
on alcohol and renal diseases, 549 
on brain in diabetes, 769 
on chorea, 950 



Dickinson on lardaceous degeneration, 97 

on rickets, 805 

on tetanus, 980 
Digestive organs, diseases of, 557 et seg. 
Dilatation of arteries (see Aneurism), 488 
of heart (see Aneurism of Heart), 473 
of lymphatics (see Lymphatic Vessels, 

Dilatation of), 528 
of oesophagus, 574 
of urinary bladder, 775 
of veins (see Varix), 499 
Diphtheria, 200 

affection of air-passages in, 204 

of deep tissues about neck in, 205 

of external parts in, 205 

of fauces and pharynx in, 203 

of kidneys in, 209 

of mouth in, 203 

of nose in, 205 

of oesophagus in, 204 
albuminuria in, 206 
bacteria in, 208 
causation of, 200 
causes of death in, 206, 207 
collapse of lungs in, 208 
definition of, 200 
duration of, 206 
history of, 200 
lobular pneumonia in, 208 
malignant, 205 
morbid anatomy of, 208 
mortality of, 206 
paralytic affections in, 207 
pathology of, 208 

structure of false membrane in, 208 

symptoms and progress of, 202 

tracheotomy in, 210 

treatment of, 209 

varieties of. 203 
Diphtherite (see Diphtheria), 200 
Disease, etiology of, 36 

(See also the different diseases) 

change of type in, 41 

definition of, 33 

physiological processes of, 51 

treatment of. 128 
Diseases of arteries, 485 et seg. 

of digestive organs, 557 et seg. 

of ductless glands, 508 et seg. 

of genito-urinary organs, 718 et seg. 

of the heart, 434 et seg. 

of the kidneys, 718 et seg. 

of the liver, 675 et seg. 

of the locomotory organs, 783 et seg. 

of the lymphatics, 524 et seg 

of the mouth, fauces, etc., 557 et seg. 

of the nervous system, 810 et seg. 

of the oesophagus, 571 et seg. 

of the pancreas, 715 et seg. 

of the pelvic organs, 774 et seg. 

of the respiratory organs, 329 et seg. 

of the skin, 274 et seg. 

of the spleen, 519 et seg. 

of the stomach, intestines, and perito- 
neum, 578 et seg. 

of the supra-renal capsules, 515 

of the thyroid body, 508 

of the urinary bladder, 774 

of the uterus, Fallopian tubes, and 
ovaries, 776 



INDEX. 



1053 



Diseases of tbe vascular organs, 434 et seq. 

of 4 the veins, 498 et seq. 
Disinfection, 144 

Disseminated sclerosis [see Sclerosis, Dis- 
seminated). 905 
Districts, cell-, 48 

Dittrich on diffusion of tubercle, 87 
Diuresis {see Diabetes Insipidus), 772 

in hysteria, 971 
Docbmius duodenalis, 634 
Donkin on diabetes, 771 
Double consciousness, 977 

treatment of, 977 
Double vision in oculo-motor paralysis, 993 
Drink, as a cause of disease, 39 
Dropped hand {see Lead-poisoning), 550, 

552 
Dropsy, 109 

abdominal {see Ascites). 655 

anaemic, 111 

anasarca, 109 

cardiac, 110 

cerebral (see Hydrocephalus), 939 
general, 109 
local, 111 
of larynx, 418 
of lungs, 418 
lymphatic, 111 
of respiratory organs, 418 
causation of, 418 
morbid anatomy of, 418 
symptoms of, 419 
treatment of, 419 
pericardial, 476 
pleural, 418 
pulmonic, 110 
renal, 110 
in scarlet fever, 165 
spinal (see Hydrorrhachis), 939 
Drunkard's liver (see Cirrhosis), 687 
Duchenne on deltoid rheumatism, 1000 
on diphtherial paralysis, 208 
on dropped hand, 522 
on functional spasm, 1002 
on glossio-labio-laryngeal palsy, 902 
et seq. 

on infantile paralysis, 887 

on locomotor ataxy, 904 et seq. 

on neuralgia, 1008 

on paralysis of musculo-spiral nerve, 
1000 

of portio dura, 997 et seq. 
on progressive muscular atrophy, 890 
et seq. 

on pseudo-hypertrophic paralysis, 914 

et seq. 

on spinal paralysis (of adults), 887 
general, 888 
Duchenne (tils) on infantile paralysis, 883 
Duckworth on tinea tonsurans, 322 
Ductless glands, diseases of, 508 et seq. 
Ducts, hepatic, inflammation of, 681 
obstruction of, 708 
pancreatic, dilatation of, 716 
obstruction of, 716 
Dupre on elimination of alcohol, 549 
Dupuy on localization of functions of brain, 
823 

Dura mater, inflammation of, 860 
causation of, 860 



Dura mater, inflammation of, morbid anat- 
omy of, 860 
morbid anatomy of (cerebral) ,860 
morbid anatomy of (chronic), 
860 

morbid anatomy of (spinal), 860 
symptoms and progress of, 862 
symptoms and progress of acute 

(cerebral), 862 
symptoms and progress of acute 

(spinal), 864 
symptoms and progress of chro- 
nic (cerebral), 864 
symptoms and progress of chro- 
nic (spinal), 868 
symptoms and progress of (in 

vertebral caries), 864 
treatment of, 867 
Dysesthesia, 842 
Dyscrasia, primary, 56 

secondary, 57 
Dysentery, 602 

causation of, 602 
definition of, 602 
morbid anatomy of, 603 
sequelae of, 606 

symptoms and progress of, 604 

terminations of, 606 

treatment of, 607 
Dyspepsia, 661 

appetite in, 751 

causation of, 661 

definition of, 749 

eructation in, 663 

flatulence in, 663 

nausea in, 664 

p;iin and uneasiness in, 662 

pyrosis in, 664 

sickness in, 664 

symptoms of, 662 

treatment of, 665 
Dysphagia, 575 
Dyspnoea, 332 



EAR, disease of, causing meningitis, &c, 
862, 878 
Enchondrosis, 75 

Ecchymosis, meaning of term, 275 
Echinococcus, description of, 629 
Eclampsia, 951, 962 

causation of, 962 

definition of, 962 

symptoms and progress of, 963 

treatment of, 963 
Ecstasy, 975 

description of, 976 

treatment of, 977 
Ecthyma (see Impetigo), 296 
Eczema, 293 

acute, 293 

causation of, 293 

chronic, 294 

description of, 293 

identity of, with lichen and strophulus, 

293 

impetiginodes, 294 

lichen agrius, a variety of, 293 

circumscriptus, a variety of, 294 

simplex, a variety of, 294 



1054 



INDEX. 



Eczema, rubrum, 294 

strophulus confertus, a variety of, 294 
intertinctus, a variety of, 294 
volaticus, a variety of, 294 
treatment of, 295 
Electric contractility of paralyzed muscles, 
836 

sensibility of paralyzed muscles, 836 
Electricity in nervous disease, 857 
(See also various disorders) 

for diagnosis, 858 

faradic or induced, 857 

galvanic or continuous, 857 

as sedative, 759 

as stimulant, 859 

for therapeutical purposes, 759 
Electrolytic treatment of hydatids. 700 
Elephantiasis, 313 

affection of lymphatics in, 313 

Arabum [see Elephantiasis) 

causation of, 313 

description of, 313 

lymphangiectodes, 314. 528 
affection of lymphatics in, 314 
filariae in blood in, 314 

treatment of, 315 
Elephas {see Elephantiasis) 
Elimination, 133 
Elliotson on hay-asthma, 432 

on iron in paralysis agitans, 914 
Elsasser on craniotabes, 806 
Embolism, 500, 502 

and chorea, 948 

causation of, 502 

consequences of, 504 

morbid anatomy of, 502 

multiple, 507 

of cerebral arteries (see Obstruction of 

Cerebral Arteries), 935 
pulmonic, 505 
pyaemic. 252 
symptoms of, 503 
treatment of, 507 
Emotional disturbance, pathology of, 856 

sensibility in chorea, 948 
Emphysema of lungs, 412 
causation of, 412 
interlobular, 412 
morbid anatomy of, 412 
symptoms and progress of, 416 
treatment of, 416 
vesicular, 413 
varieties of, 413 
Emprosthotonos, 979 
Empyema, 379, 381 

consequences of, 379, 382 
Encephalitis, 876 

causation of, 876 
morbid anatomy of, 877 
symptoms and progress of, 878 
treatment of, 882 
Encephaloid cancer, 92 

(See also Morbid Growths) 
Enchondroma, 75 
Endemic, in relation to fevers, 137 
Endoarteritis, 486 
causation of, 486 
morbid anaiomy of, 486 
symptoms of, 487 
syphilitic, 486 



Endocarditis, 459, 464 
causation of, 464 
morbid anatomy of, 464 
prognosis of, 466 
symptoms and progress of, 465 
treatment of, 466 
ulcerative, 507 
Endopathic causes of disease, 43 
Enostoses, 76 
Enteric fever, 210 

causation of, 210 
causes of death in, 217 
complications of, 216 
decomposing feces in relation to, 211 
definition of, 210 
diagnosis of, 218 
history of, 211 
intestinal disease in, 218 
intestinal hemorrhage in, 217 
intestinal perforation in, 216 
mesenteric gland affection in, 219 
morbid anatomy of, 218 
mortality in, 218 
peritonitis in, 216 
pulmonary affection in, 217 
spleen, enlargement of, in, 219 
symptoms and progress of, 212 
treatment of, 220 
varieties of, 215 
vegetable organisms in, 220 
Enteritis, 585 

catarrhal, 586, 587 
causation of, 585 
morbid anatomy of, 586 
symptoms and progress of, 587 
chronic, 587 
pellicular, 5S6, 587 
phlegmonous, 585, 587 
treatment of, 589 
Entozoa (see Parasites and Parasitic Dis- 
eases, or Morbid Growths of Different 
Organs) 

Epidemic catarrh (see Influenza), 146 

cerebro-spinal meningitis (see Cerebro- 
spinal Fever), 197 
cholera, 232 

algide stage in, 227 

causation of, 222 

collapse in, 227 

death in, 227, 228 

definition of, 222 

diagnosis of, 229 

epidemic extension of, 222 

history of, 222 

incubation of, 226 

injection of saline salts in, 232 

morbid anatomy of, 230 

mortality of, 229 

outbreak in India, 222 

pathology of, 230 

premonitory diarrhoea in, 226 

RadclifiVs, Mr., investigations, 225 

reaction in, 227 

relation of, to diarrhsea, 229 

Sanderson's experiments as to trans- 
mission of, 225 

Schmidt's solution for injection in, 
233 

Snow's investigations, 224 
specific fungus in, 223 



INDEX. 



1055 



Epidemic cholera, symptoms find progress 
of, 226 

telluric and atmospheric causes of, 
223 

Thiersch, experiments as to trans- 
mission of, 225 

treatment of, 232 

varieties of, 229 
constitution, 41 
diseases, management of, 144 
in relation to fevers, 137 
roseola, 158 

causation of, 158 

definition of, 158 

diagnosis of, 159 

incubation of, 159 

symptoms and progress of, 159 
Epilepsia gravior, 955 

mitior, 955 
Epilepsy, 951 

causation of, 952 
definition of, 951 
diagnosis of, 959 
feigned, 959 
morbid anatomy of, 959 
pathology of, 959 

spinal, in disseminated sclerosis, 881 
symptoms and progress of, 952 
treatment of, 96 1 
Epileptic attack, description of, 952 
aura in, 953 

clonic convulsions in, 954 
coma in, 955 
cry in, 954 

exciting causes of, 957 

recurrence of, 956 

tonic convulsions in, 954 

unconsciousness in, 953 
mania, 960 
state, 957 
vertigo, 955 

varieties of, 955 
Epileptiform neuralgia (see Tic Douloureux), 
1003 

Epiphora in paralysis of the portio dura, 997 
Epithelial tissues, 47 
Epithelioma, 94 

(See also Morbid Growths) 
Equinia. (see Glanders), 236 
Erysipelas, 278 

a specific fever, 279 

bacteria in, 279 

causation of, 278 

contagiousness of, 278 

definition of, 278 

erratic, 279 

hypertrophy in, 280 

idiopathic, 278 

in smallpox, 171 

larynx, involvement of, in, 280 

meninges, involvement of, in, 280 

morbid anatomy of, 279 

phlegmonous, 281 

pneumonia in, 281 

serous membranes, extension of, to, 280 
simple, 281 

symptoms and progress of, 281 
traumatic, 278 
treatment of, 282 
varieties of, 2 1 1 



Erysipelas, veins, extension of, to, 279 
Erythema, 284 

causation of, 284 

circinatum, 285 

(See also Tinea Tonsurans, 321) 

description of, 284 

fugax, 286 

gyratum, 286 

identity of, with roseola, urticaria, and 

pityriasis, 286 
in nervous diseases, 846 
in rheumatism, 786 
intertrigo, 285 
iris, 285 
Iseve, 285 
marginatum, 286 
multiforme, 286 
nodosum, 286 
papulatum, 286 

pityriasis capitis, a form of, 286 

simplex, a form of, 285 
purpura urticans, a variety of, 2S7 
roseola, a variety of, 287 

autumnalis, a variety of, 287 
simplex, 285 
tuberculatum, 286 
treatment of, 288 
urticaria, a variety of, 287 
Esquirol, definition of insanit}', 1010 
Essential paralysis (see Paralysis, Spinal 

Infantile), 882 
Etherization in hysteria, 973 
Etiology of disease (see iEtiology) 
Eulenburg on pulse in tabes dorsalis, 898 
Exanthem, or exanthema, meaning of teim, 
274 

Exanthemata, Wilkin's third order, 274 
Exciting causes, 36, 42 
Excretion in health, 49 
Exopathic causes of disease, 43 
Exophthalmic goitre (see Graves's Disease), 
477 

Exostosis, 76 
Expectoration, 334 
bloody, 334 
fetid, 335 
nummulated, 335 
of foreign bodies, 335 
plastic (casts of tubes), 335 
pneumonic, 335 
purulent, 334 
Exudation, inflammatory, 64 
Eyes, affection of, in syphilis, 242 

in disseminated sclerosis, 907 

in inflammation of dura mater, 863 

in meningitis, 871, 873 

in morbid growths of the brain, 921 

in oculo-motor paralysis, 991 

in renal disease, 735 

in spinal disease, 866 

in tabes dorsalis, 897 



FACIAL neuralgia (see Tic Douloureux), 
palsy (see Paralysis of the Portio 
Dura), 996 
Fagge, H., on compression of bowel, 645 
and Durham on electrolytic treatment 

of hydatid cysts, 70 I 
on scleroderma, 311, 31 2 



1056 



INDEX. 



Fagge on thyroid body, 513 

on xanthoma, 309 
Fallopian tubes, dilatation of, 778 

tubercle of, 778 
Falret on epileptic mania, 960 
False membrane in diphtheria, 208 
Famine fever {see Kelapsing Fever), 189 
Faradic {see Electric) 
Faradism {see Electricity) 
Farcy (see Glanders), 236 

buds, 237 
Fatty degeneration, 98 
of heart, 470 

symptoms of, 471 
treatment of, 473 
of liver {see Liver, Fatty), 702 
growth of heart, 468 

symptoms of, 469 
tumors, 74 
Fauces, gangrene of, 563 
causation of, 563 
symptoms and progress of, 563 
treatment of, 564 
syphilitic disease of, 571 
tubercle of, 571 
Favus {see Tinea Favosa), 323 
Febris rubra {see Scarlet Fever), 160 
Fehling's test for sugar, 725 
Fermentation test in diabetes, 727 
Ferrier on localization of cerebral functions, 

821 et seq. 
Fever, 112 

blood in, 116 

causes of death in, 117 

causes of high temperature in, 118 

cerebro-spinai {see Cerebro-spinal 

Fever), 198 
congestive, 269-272 
crisis in, 116 
dandy {see Dengue), 193 
enteric {see Enteric Fever), 210 
famine {see Relapsing Fever), 189 
hay {see Hay-Astbma), 431 
heat, 986 

use of ice in, 986 
of morphia in, 986 
hectic, 119 

intermittent {see Ague), 263 
lysis in, 116 
pernicious, 269-272 
relapsing {see Relapsing Fever), 189 
remittent {see Ague), 263 
rheumatic (see Rheumatism), 783 
scarlet {see Scarlet Fever), 160 
symptoms of, 114 

referable to alimentary canal in, 115 

to heart in, 1 15 

to lungs in, 115 

to nervous system in, 116 

to skin in, 115 
temperature in, 114 
thermic, 986 
thermometer in, 118 
typhoid {see Enteric Fever), 210 
typho-malarial, 273 
typhus {see Typhus Fever), 182 
urine in, 115 
waste of tissue in, 116 
Fevers, propbylactic treatment of, 144 
specific, 137 et seq. 



Fevers, specific, causes of, 137 
Fibroid degeneration of heart, 471 

phthisis {see Cirrhosis), 385 
Fibroma, 73 
Fibrous tumors, 73 

Fifth nerve, neuralgia of {see Tic Doulour- 
eux), 1003 
paralysis of, 995 

causation of, 995 
symptoms and diagnosis of, 995 
treatment of, 996 
ulceration of cornea in, 996 
Filaris sanguinis hominis, 636, 763 
Flax dressers' phthisis, 387 
Flint, A., Jun , on cholesterine in bile, 677 
Flourens on semicircular canals, 826, 989 
Folie circulaire, 1023 
raisonnante, 1028 
Food, as cause of disease, 39 
Foreign bodies, impaction of, in bowels {see 

Impaction, etc.), 646 
Fox, Wilson, on diarrhoea in dyspepsia, 665 
on inoculation of tubercle, 87 
on origin of cysts, 107 
Frank on hydrocephalus, 943 
Fremitus, vocal, 338 

Frerichs, on conversion of urea into ammo- 
nia, 734 
on fatty liver, 702 
on jaundice, 678, 679, 712 
on jaundice in pyaemia, 255 
on malignant jaundice, 714 
on pyrosis, 664 
on situation of liver, 674 
Friction sounds, pericardial, 449 

pleural, 354 
Friedreich, on hepatic pulsation, 448 
Functional derangements, 103, 107 
collapse, 122 
congestion, 108 
death, 124 
dropsy, 109 
fever, 112 
hectic, 119 
syncope, 122, 123 
typhoid condition, 120 
spasm and paralysis (local), 1001 
causation of, 1001 
definition of, 1001 
diagnosis of, 1001 
pathology of, 1001 
symptoms of, 1001 
treatment of, 1003 
Furfura, meaning of term, 276 
Furunculus {see Carbuncle), 282 



("i AIRDNER, on asthma, 430 
J on delirium tremens, 549 

on prsesystolic murmur, 454 
on pulmonary collapse, 420 
Galabin, on pulse trace, 439 
Gall bladder, dilatation of, 709 
mucous cyst of, 709 
shrivelling of, 709 
ducts {see Hepatic Ducts), 681, 709 
stones, 704 

causation of, 704 

chemical constitution of, 705 

consequences of, 706 



INDEX. 



1057 



Gall-stones, impaction of, in bowels (see j 
Impaction of Foreign Bodies in 
Bowels) , 646 
morbid anatomy of, 705 
size and shape 5 of, 705 
symptoms and progress of, 706 
treatment of, 708 
Galvanic (see Electric) 
Galvanism (see Electricity) 
Gangrene, 67, 101 
in leprosy, 262 

of fauces (see Fauces, Gangrene of), 564 
of lung, in pneumonia, 458 
of mouth, 563 
Garrod, on gout, 795 et seq 

on lead-poisoning, 551 
on rheumatism, 789 
on rheumatoid arthritis, 793 
on scurvy, 537 
Gastric (see Stomach) 
Gastritis, 581 

causation of, 581 
morbid anatomy of, 582 
symptoms and progress of, 582 
of acute, 582 
of chronic, 582 
of mild, 582 
treatment of, 584 
Gastrodynia, 662, 667 
Gee, on scarlet fever, 163 
General paralysis, 1032 

congestive variety, 1033 
expansive variety, 1034 
melancholic variety, 1035 
paralytic variety, 1033 
Generalization of morbid growths, 52 
Genito-urinary organs, diseases of, 718 et 
seq. 

Giant-cells in tubercle, 83 

Gingivitis (see Gums, Inflammation of), 564 

Glanders, 236 

causation of, 236 

chronic form of, 237 

definition of, 236 

diagnosis of, 237 

farcy, 236 

history of, 236 

incubation of, 236 

morbid anatomy of, 236 

results of, 237 

symptoms and progress of, 236 
treatment of, 238 
tubercles of (farcy buds), 237 
Glandular laryngitis, 356 
Glioma, 75 

of brain and cord (see Morbid Growths), 
917,918 
Globus hystericus, 968 
Glossitis, 565 

causation of, 565 
symptoms and progress of, 565 
treatment of, 566 
Glosso-labio laryngeal palsy, 902 
causation of, 902 
definition of, 902 
morbid anatomy of, 902 
symptoms and progress of, 902 
treatment of, 904 
Glossy skin, 846 
Glucose in urine, 725 

67 



Glue-like tumor, 75 
Glycosuria (see Diabetes), 766 
Goitre, 508 

causation of, 508 

exophthalmic (see Graves's Disease), 
477 

morbid anatomy of, 509 
sub-maxillary, 510 
sub-sternal, 510 
symptoms and progress of, 510 
treatment of, 511 
varieties of, 509 
Gonorrhceal rheumatism, 788 
Goodeve, on raw meat in diarrhoea, 673 
Goodhart, on syphilitic diseases of lungs, 

403 
Gout, 793 

causation of, 793 
chalk stones (or tophi) in, 795 
definition of, 793 
morbid anatomy of, 794 
pathology of, 799 
symptoms and progress of, 796 
treatment of, 800 
Gowers on hydrophobia, 235 

on leucocythaemia, 529 
Gr'afe, von, on Graves's disease, 480 
Granular degeneration of heart, 47 L 
Granulation, 67 
Granuloma, 83 
Grape-sugar in urine, 725 
Gravel (see Urinary Concretions), 757 
Graves on chorea, 941 
Graves's disease, 478 

causation of, 478 
definition of, 478 
enlargement of thyroid in, 479 
morbid anatomy of, 478 
palpitation in, 479 
protrusion of eyeballs in, 479 
symptoms and progress of, 478 
treatment of, 480 
Gray hepatization of lung, 369, 371 

induration of lung, 387 
Green, T. Henry, on phthisis, 393 
Greenfield on adenoid cancer (note), 95 
on hydrophobia, 235 
on syphilitic disease of lungs, 403 
on syphilitic endo-arteritis, 487 
on tubercle of spinal meninges, 869 
Greenhow, H., on cirrhosis of lungs, 387 

on paracentesis of hydatid cysts, 700 
Green-sickness (see Anaemia), 531 
Gregory on statistics of smallpox inocula- 
tion, 175 

Griffin, Messrs., on spinal irritation, 972 
Grocers' itch (see Eczema), 294 
Growth ir> health, 49 . 

morbid (see Morbid Growth), 51 
Growths, morbid (see Tumors), 51 et seq. 
(See also Morbid Growths and Tumors of 
Different Organs) 
Grube on filaria, 637 
Guerin on rickets in puppies, 802 
Gull, Sir W., on factitious urticaria, 283 
on hydrorrhachis, 944 
on myxoedema, 513 et seq. 
on vitiligoidea, 309 
and Dr. Sutton on abscess of brain 
878 



1058 



INDEX. 



Gull, Sir W., and Dr. Sutton on hyaline- 
fibroid change of vessels, 734 
Gummata, 87 

{see Syphilis), 238 ; {see also Syphilitic 
Diseases, or Morbid Growths of Dif- 
ferent Organs) 
Gums, inflammation of, 564 
Gurgling, 352 



HABITS as causes of diseases, 39 
Haematemesis {see Hemorrhage from 
Stomach, etc.), 658 
Haematoidine crystals, 99 
Ilsematinuria, 765 
Haematuria, 729 

causation of, 764 
paroxysmal, 764 
causation of, 765 
definition of, 764 
pathology of, 765 
symptoms and progress of, 765 
treatment of, 766 
symptoms of, 764 
treatment of, 764 
Haemic murmurs, 455 
Haemophilia, 540 

affection of joints in, 542 
analysis of the blood in, 542 
causation of, 540 
diagnosis in, 544 
Dr. Immermann on, 540 
Dr. Wickham Legg on, 540 
hereditary predisposition to, 540 
morbid anatomy and pathology of, 542 
prognosis in, 544 
symptoms of, 541 
treatment of, 544 
Haemoptysis, 335 

{See also Hemorrhage of Respiratory 
Organs, 421) 
Haemorrhage {see Hemorrhage) 
Haldane on carbonate of lime calculi, 733 
Halford, Sir H., on catarrh, 559 
Hall, Marshal], on epilepsy, 960 
Hallier on cholera-fungi, 224 
on oidium albicans, 560 
Hallucinations in insanity, 1014 
Hammond on athetosis, 841 
Hanot on hypertrophic cirrhosis, 689 
Hare on treatment of hysteria, 974 
Harley, George, on biliary acids in urine, 
678, 679, 729 
on ox-gall in jaundice, 712 
on paroxysmal haematuria, 764 
Jno., on bilharzia in urine, 755 
Has sail on lead poisoning, 551 
Haut mal {see Epilepsy) , 951 
Hay-asthma, or hay-fever, 431 
causation of, 431 
definition of, 431 
symptoms and progress of, 431 
treatment of, 431 
Headache, 849 

in Bright's disease, 748 
in megrim, 986 
varieties of, 849 
Health, physiological processes in, 46 
Hearing, affection of, in megrim, 987 
in Meniere's disease, 990 



Heart, action of, 436 

anatomical relations of, 4341 
aneurism of {see Aneurism of Heart), 
473 

atrophy of, 441 

bulbous condition of fingers in disease 

of, 447 
debility of, 441 

diagnosis of, 452 

prognosis of, 455 

treatment of, 457 
degeneration of, 470 

causation of, 470 

fatty, 470 

fibroid, 471 

granular, 471 

morbid anatomy of, 470 

symptoms of, 471 

treatment of, 473 
diagnosis, general, of cardiac derange . 
ments, 448 

special, of cardiac derangements, 
451 

area of cardiac dulness, 448 
form of praecordial region, 448 
diastolic murmurs, 450 
direct murmurs, 450 
endocardial murmurs, 450 
increased resistance, 449 
pericardial friction, 449 
praesystolic murmur, 450 
pulsation, 449 
regurgitant murmurs, 450 
systolic murmurs, 450 
thrill, 449 

venous murmurs, 451 
dilatation of, 445 
cause of, 445 
dimensions of, 434 
disease in chorea, 945 
diseases of, 434 et seq. 
displacement of, 441 
effects of derangements of, on heart, 
445 

in causing dilatation, 445 
in causing hypertrophy, 445 
on organism, 447 
fatty growth of {see Fatty Growth of 

Heart) 
form of, in disease, 447 
functional derangements of, 444 
motor, 444 
sensory, 445 
hepatic pulsation in disease of, 448 
hypertrophy of, cause of, 441, 445 
diagnosis of, 451 
in renal disease, 734 
prognosis of, 455 
treatment of, 457 
inflammation of {see Myo- and Endo- 
carditis), 463, 464 
malformations of {see Malformations of 

Heart), 483 
malignant diseases of, 469 
mechanical derangements of, 440 

from conditions of contents, 443 
from conditions of valves, 443 
from conditions of walls, 442 
from external conditions, 441 
morbid growths of, 468 



INDEX. 



1059 



Heart, neuralgia of (see Angina Pectoris), 
480 

parasitic disease of, 470 

pathology of, 441 et seq. 

physiology of, 436 

pyaemic affection of, 250 

rupture of, 475 

causation of, 475 
morbid anatomy of, 475 
symptoms and progress of, 475 

sounds of, 437 

syphilitic disease of, 245, 468 
thrombosis of 500, 505 
tubercle of, 468 

venous pulsation in disease of, 448 
Heat, as cause of disease, 40 
Hebra on acarus scabiei, 318 

on acne rosacea, 304 

on eczema, 295 

on elephantiasis, 314 

on erysipelas, 278, 282 

on erythema, 286 

on lichen ruber, 310 

on pityriasis rubra, 290 

on prurigo, 327 

on psoriasis, 289 
Hectic fever, 119 

symptoms of, 119 
Helmerich's ointment for scabies, 319 
Helmholtz on hay-asthma, 431 

on muscles of eyeball, 992 
Hemianaesthesia, 838 

in cerebral hemorrhage, 931, 932 

in hysteria, 969 

in morbid growths of brain, 921 

in obstruction of cerebral arteries, 938 
Hemicrania (see Megrim), 985 
Hemiplegia, 841 

in cerebral hemorrhage, 929 

in hysteria, 970 

in morbid growths of brain, 921 
in obstruction of cerebral arteries, 
938 

Hemorrhage from bowels in enteric fever, 
214, 216 

cerebral {see Cerebral Hemorrhage), 
926 

of cord (see Spinal Hemorrhage) , 926 

into pericardium, 475 

of respiratory organs, 334, 421 

causation of, 421 

morbid anatomy of, 421 

symptoms and progress of, 423 

treatment of, 423 

varieties of, 470 
from stomach and bowels, 658 

causation of, 658 

symptoms and progress of, 659 

treatment of, 660 
from urinary organs (see Haematuria), 
764 

Hemorrhagic diathesis, 540 
Hepatic abscess (see Hepatitis) 
diseases, 663 et seq. 
ducts, inflammation of, 681 
causation of, 681 
morbid anatomy of, 681 
symptoms and progress of, 681 
treatment of, 682 
obstructions of, 708 



I Hepatic ducts, obstructions of, biliary tox- 
aemia in, 711 
causation of, 708 

dilatation as a consequence of, 709 
jaundice in, 710 
morbid anatomy of, 709 
perforation as a consequence of, 709 
symptoms and progress of, 710 
treatment of, 711 
pulsation in heart-disease, 447 
Hepatization, gray, of lungs, 368, 369, 370 
red, of lungs, 368, 369, 370 
white, of lungs (see Syphilitic Disease 
of Respiratory Organs), 403 
Hepatitis, 682 

causation of, 682 
morbid anatomy of, 682 
symptoms of, 684 
treatment of, 686 
Heredity as cause of disease, 38 
Herpes, 298 

causation of, 298 
circinatus, 300, 322 
description of, 298 
in pneumonia, 374 
iris, 299 

relation of, to erythema, 298 

simplex, 299 

treatment of, 301 

varieties of, 298 

zoster, 298 
Heterologous tumors, 73 
Heubner on syphilitic endo-arterifcis, 486 
Heuter on bacteria in diphtheria, 207 
Heydenreich on spirilla in relapsing fever, 
142 

Hob nail liver, 687 
Homologous tumors, 73 
Hooping-cough, 149 

causation of, 149 

complications of, 151 

convulsions in, 151 

definition of, 149 

duration of, 151 

incubation of, 149 

morbid anatomy of, 152 

mortality of, 152 

symptoms and progress of, 149 

treatment of, 152 

Hunter, Jno., on identity of gonorrhoea 
and syphilis, 238 
Hutchinson, Dr., on the spirometer, 339 
J. , on syphilis, 247 
on xanthoma, 310 
Hydatid thrill, 698 
Hydatids, 629 

of brain and cord (see Morbid Growths), 

919, 924 
of heart, 470 

of kidney (see Kidney, Hydatids of), 
755 

of liver (see Liver, Hydatids of), 698 

of lungs, 408 

of spleen, 523 
Hydrencephalocele, 940 
Hydrocephalic cry, 871 
Hydrocephalus, 939 

acute (see Meningitis), 869 

causation of, 939 

chronic, 940 



1060 



INDEX. 



Hydrocephalus, morbid anatomy of, 939 

symptoms and progress of, 942 

treatment of, 944 
Hydromeningocele, 940 
Hydronephrosis, 760 

causation of, 760 

morbid anatomy of, 760 

symptoms and progress of, 761 

treatment of, 761 
Hydro-pericardium, 476 
Hydrophobia, 233 

causation of, 233 

definition of, 233 

in dogs, 234 

duration of, 235 

excitement stage of, 234 

history of, 233 

incubation of, 234 

melancholic stage of, 234 

morbid anatomy of, 234 

mortality of, 233 

sub-lingual vesicles in, 236 

symptoms and progress of, 234 

treatment of, 236 
Hydrorrhachis, 939 

causation of, 939 

external (spina bifida), 940 

internal, 942 

morbid anatomy of, 939 

symptoms and progress of, 942 

treatment of, 944 
Hydrothorax (see Dropsy of Respiratory 

Organs), 418 
Hygiene, 128 
Hygienic treatment, 128 
Hyperesthesia, 842 

in hysteria, 968 
Hyperplasia, 58 
Hyperpyrexia, 114 
Hypertrophy, 58 

of heart [see Heart, Hypertrophy of), 
445, 452, 455, 456 

of spleen (see Spleen, Hypertrophy of), 
520 

Hypodermic injection of strychnia in in- 
fantile paralysis, 887 
Hysteria, 965 

alimentary canal, affection of, in, 971 

anaesthesia in, 969 

aphonia in, 970 

causation of, 965 

clavus in, 968 

convulsions in, 967 

definition of, 965 

diagnosis of, 972 

diuresis in 97 1 

globus hystericus in, 968 

hemiplegia in, 970 

hyperesthesia in, 968 

joints, affections of,, in, 972 

larynx, affections of, in, 970 

mammas, affections of, in, 972 

mania in, 967 

mental condition in, 966 

ovaries, condition of, in, 969 

paralysis in, 969 

paraplegia in, 969 

pathology of, 973 

reproductive organs, affections of. in, 
971 



Hysteria, spasms in, 967 

spinal irritation in, 972 
spine, affections of, in, 972 
suppression of urine in, 971 
symptoms and progress of, 966 
treatment of, 973 

urinary organs, affections of, in, 971 



TCHOR, 66 

1 Ichthyosis, 291 

cornea, 292 

simplex, 291 

treatment of, 292 
Icterus (see Jaundice) 
Idiocy, 1037 

Illusions in insanity, 1014 
Immermann on haemophilia, 540 
Impaction of foreign bodies in bowel, 646 
causation of, 646 
morbid anatomy of, 646 
symptoms and progress of, 647 
treatment of, 653 
Impetigo, 296 

causation of, 296 
description of, 296 
erysipelatodes, 296 
figurata, 296 
corrigo larvalis, 296 
scabida, 296 
sparsa, 296 
sycosis, 297 
treatment of, 297 
Impure air, as cause of disease, 40 
lndican in urine, 725 
Indigestion (see Dyspepsia), 650 
Indigo in urine, 725 

calculus, 733 
Induration, black, of lungs, 387 
brown, of lungs, 387 
gray, of lungs, 387 
red, of lungs, 387 
Infantile convulsions, 951, 963 
causation of, 963 
definition of, 963 
symptoms and progress of, 963 
treatment of, 964 
paralysis (see Paralysis, Spinal Ii 
fantile), 884 
Infection, in relation to fevers, 138 
Inflammation, general pathology of, 60 
abscess in, 66 

cause of change of size in vessels, in, 

varying rates of blood-flow in, 63 
cicatrization after, 68 
constitutional effects of, 70 
destructive processes in, 66 
extravascular processes in, 60 
exudation in, 64 
gangrene in, 66 
granulation in, 67 
ichor in, 65 
in cartilage, 60 
in cornea, 62 
in mesentery, 61 
migration of leucocytes in, 63 
organization in, 67 
pus-cells in, 65 

redness, swelling, heat and pain in, 59 
repair after, 68 



INDEX. 



10G1 



Inflammation, sanies in, 65 

spread of, 69 

stasis of blond in, 63 

suppuration in, 65 

ulceration in, 66 

varieties of, 70 

vascular processes in, 62 

in vascular tissues, 62 

vessels, dilatation of, in, 62 
Inflammation, local 

of arteries (see Arteritis), 485 

of bowels (see Enteritis) , 585 

of brain (see Encephalitis) , 876 

of bronchial tubes (see Bronchitis) , 361 

of cord (see Myelitic), 876 

of dura mater, 860 

of endocardium (see Endocarditis), 464 
of gums (see Gums, Inflammation of), 
564 

of hepatic ducts, 681 

of joints (see Rheumatism), 783 

of kidney (see Nephritis and Pyelitis, 

and acute Bright's Disease), 736, 739, 

740 

of kidney, chronic (see Chronic Bright's 
Disease), 744 

of larynx (see Laryngitis), 355 

of liver (see Hepatitis, 681 

chronic (see Cirrhosis), 687 

of lungs (see Pneumonia), 368 
chronic (see Cirrhosis), 385 

of lymphatics (see Lymphatics, Inflam- 
mation of), 524 

of meninges (see Meningitis), 868 

of mouth, fauces, etc. (see Catarrh, 
Thrush. Stomatitis, Noma), 557, 560, 
562, 563 

of muscular walls of heart (see Myocar- 
ditis), 464 

of nervous centres, chronic (see Scle- 
rosis), 882 

of oesophagus (see (Esophagus, Inflam- 
mation of), 572 

of oesophagus, ulcerative, 572 

of ovaries, 776 

of pancreas, 716 

of pericardium (see Pericarditis), 459 
of peritoneum (see Peritonitis), 608 
of pleura (see Pleurisy), 376 
of skin (see Erysipelas and other skin 
diseases) 

of spleen (see Spleen, Inflammation of), 
521 

of stomach (see Gastritis), 581 
of thyroid body, 508 
of tongue (see Glossitis), 565 
of tonsils (see Quinsy), 566 
of trachea (see Tracheitis), 355 
of urinary bladder, 774 
of uterus, 776 
of veins (see Phlebitis), 498 
Influenza, 146 

causation of, 146 
complications of, 147 
definition of, 146 
diagnosis of, 148 
duration of, 148 
history of, 146 
incubation of, 147 
morbid anatomy of, 148 



Influenza, mortality of, 148 

relation of, with cholera, 146 
symptoms and progress of, 147 
treatment of, 148 

Innocent, meaning of, as applied to tu- 
mors, 58 

Inoculation for smallpox, 168, 175 

of specific fevers, 138 
Insanity, 1008 

causes of, exciting, 1011 

predisposing, 1010 
definition of, 1008 
disorders, intellectual in, 1015 
of movement, in, 1018 
of sensation, in. 1014 
pathology and morbid anatomy of, 1039 
prognosis in, 1038 
symptoms and progress of, 1013 
treatment of, 1042 
moral, 1042 
therapeutic, 1043 
varieties of, 1020 
dementia, 1030 
general paralysis, 1032 
idiocy, 1037 
mania, 1025 
melancholia 1021 
monomania, 1029 
Insolatio (see Sunstroke), 981, 982 
Insular sclerosis (see Sclerosis, Dissemi- 
nated), 905 
Intermittent fever (see Ague) , 262 
Intestinal glands, affection of, in cholera, 
230 

in enteric fever, 218 
hemorrhage in enteric fever, 216 
worms (see also different worms), 626 
Intestines, diseases of (see Stomach, Intes- 
tines, and Peritoneum, Diseases of), 578, 
et seq. 
Intussusception, 648 
causation of, 648 
morbid anatomy of, 648 
symptoms and progress of, 649 
treatment of, 650 
Invagination (see Intussusception) 
Irritability of paralyzed muscles, 836 
Ischuria renalis (see Urine, Suppression of), 
773 

Itch (see Scabies), 317 



JACCOUD on reflex action 922 
Jackson, H , on chorea, 949 
on convulsions, 842 
on convulsions in cerebral tumor, 922 
on disease of optic thalamus, 824, 839 
on headache, 849 
on retinal vessels in epilepsy, 960 
Jaundice, 677 

bilious toxaemia in, 681 
connected with gall-stones, 707 
in ague, 270 
in dengue, 194 
in heart-disease, 447 
in hepatic disease (see Hypertrophic 
Cirrhosis and other diseases), 681 et 
seq. 

in pneumonia, 373 
in pyaemia 254 



1062 TND 

Jaundice, in relapsing fever, 191 
malignant, 713 

causation of 713 

definition of, 713 

morbid anatomy of, 714 

symptoms and progress of, 713 

treatment of, 715 
obstructive, 710 
pathology of, 677 
symptoms of, 679 
without obstruction, 712 

causation of, 712 

morbid anatomy of, 712 

symptoms of, 712 

treatment of, 712 
in yellow fever, 196 
Jenner, B., on vaccination, 178 et seq. 

Sir W., on rickets, 802, 804 
Johnson, Geo., on cholera, 231 
on enteric fever, 221 
on renal disease, 734 
on sunstroke, 985 
Joint-affection in gout {see Gout), 793 

in hysteria, 972 

in nervous diseases, 845 

in pyaemia, 251 

in rheumatism {see Rheumatism), 
783 

in rheumatoid arthritis {see Rheu- 

matoid Arthritis), 791 
in rickets {see Rickets), 801 
in syphilis, 244 
in tabes dorsalis, 898 
in typhus, 187 
Jurgensen on temperature, 112 



KELTS {see Keloid), 308 
Keloid, 308 
Addison's {see Scleroderma), 311 
causation of, 308 
description of, 308 
false, 309 
treatment of, 309 
Keratitis, in congenital syphilis, 247 
Kidney, affection of, in diphtheria, 206, 
208 
in gout, 795 
in hysteria, 971 
in lead-poisoning, 551 
in nervous diseases, 821 
in pyaemia, 251, 255 
in scarlet fever, 163, 165 
in syphilis, 245 
atrophy of {see Hydronephrosis), 760 
bilharzia haematobia in, 755 

treatment of, 756 
carcinoma of {see Morbid Growths of), 
753 

congestion of, 757 

causation of, 751 

morbid anatomy of, 755 

symptoms of, 755 

treatment of, 755 
contracted granular {see Brigbt's Dis- 
ease, chronic interstitial) 746 
cystic {see ditto), 747 
diseases of, 718 et seq. 
fatty {see Bright's Disease, chronic pa- 
renchymatous), 744 



EX. 

Kidney, general considerations in relation 
to diseases of, 718 
hydatids of, 755 

treatment of, 755 
inflammation of {see Nephritis and 

Bright's Disease) 
lardaceous degeneration of, 756 
causation of, 756 
morbid anatomy of. 756 
symptoms and progress of, 756 
treatment of, 756 
large white {see Bright's Disease, chronic 

parenchymatous), 744 
lymphadenoma of {see Morbid Growths 

of), 753 
misplaced {see Movable), 761 
morbid growths of, 753 
anatomy of, 753 
symptoms and progress of, 754 
treatment of, 755 
movable or floating, 761 
symptoms of, 761 
treatment of, 762 
parasitic affections of, 755 
suppuration of {see Pyelitis, 736, and 

Suppurative Nephritis, 739) 
syphilitic disease of, 753 
tubercle of. 752 

morbid anatomy of, 752 
symptoms and progress of, 752 
treatment of, 753 
Kirkes, on embolism as cause of chorea, 
949 

Klein, on contagium of enteric fever, 220 
on scarlatinal nephritis, 165, 741 
on tubercle, 85 

Knapp's test for sugar, 727 

Koch, on bacilli anthracis, 142 

Koster, on epithelioma, 95 

Kuchenmeister, on acarus folliculorum, 321 
on pediculi, 316 

Kiihne, on biliary acids in urine, 679 

LAENNEC on tubercle, 83, 87 
Lancereaux on pachymeningitis, 864 
on syphilis, 240 
Lardaceous degeneration, 97 

of kidney {see Kidney, Lardaceous 

Degeneration of), 756 
of liver {see Liver, Lardaceous De- 
generation of), 703 
of spleen {see Spleen, Lardaceous 
Degeneration of), 523 
Laryngeal phthisis, 356, 359 

{See also Tubercle of Respiratory Or- 
gans, 395) 
syphilis, 356, 359 
Laryngismus stridulus, 358, 964 
Laryngitis, 355 
acute, 356 

aphonia clericorum, 359 
causation of, 355 
chronic, 359 
complications of, 358 
cough in, 358 
dyspnoea in, 357 
glandular, 356 
morbid anatomy of, 355 
phthisical, 356, 359 



INDEX. 



1003 



Laryngitis, spasmodic attacks in, 358 

symptoms and progress of, 356 

syphilitic, 356, 360 

treatment of, 360 

voice in, 357 
Laryngoscope, 336 
Larynx, anatomical relations of, 329 

congestion of (see Congestion of Respi- 
ratory Organs), 417 

hysterical affection of, 970 

inflammation of (see Laryngitis), 355 

morbid growths of (see Morbid Growths 
of Respiratory Organs), 404 

oedema of (see Dropsy of Respiratory 
Organs), 418 

paralysis of (see Paralytic Affections of 
Larynx), 425 

spasms of, 427 

syphilitic disease of, 356, 359 

(See also Syphilitic Disease of Respi- 
ratory Organs), 402 
tubercle of, 356, 358 
Lateral sclerosis (see Sclerosis, Lateral), 
892 

Latham, on megrim, 989 
Laycock, on delirium tremens, 549 
Lead colic, 551 
palsy, 550 

poisoning, chronic, 550 
causation of, 550 
colic in, 551 
dropped hand in, 552 
morbid anatomy and pathology of, 
553 

symptoms and progress of, 551 

treatment of, 554 

use of, as a cosmetic, 551 

Leared, on binaural stethoscope, 345 

Lee, H., on syphilis, 239 

Legg, Dr. Wickham, on haemophilia, 540 

Leidy, on filaria, 637 

Lenke, on amaurosis in baematemesis, 660 
Leontiasis (see Leprosy), 259 
Lepra (see Psoriasis), 389 
Leprosy, 257 

anaesthetic, 259 

a specific disease, 259 

causation of, 257 

causes of death in, 261 

contagiousness of, 258 

definition of, 257 

destruction of bones in, 262 

duration of, 261 

gangrene in, 262 

history of, 257 

internal organs affection of, in, 262 
leontiasis in, 260 
macular, 259 

morbid anatomy and pathology of, 261 
nerve-affection in, 261 
symptoms and progress of, 259 
treatment of, 262 
tubercles, development of, in, 261 
tubercular, 259 
Leptus autumnalis, 321 

Letzerich on inoculation of diphtheria, 202 
Leucine, 724 

Leuckart, on trichina spiralis, 630 
Leucocytes, migration of, 52, 63 
Leucocythaemia, 82, 529 



Leucocythaemia, causation of, 529 

definition of, 529 

morbid anatomy of, 530 

symptoms and progress of, 530 

treatment of, 531 
Leucophlegmasia, 530 
Lukaemia, 82, 529 

Lewis, T. R., on filariae in blood, 314, 636 

et seq., 763 
Lice (see Phthiriasis), 316 
Lichen (see Eczema), 293 
circinatus, 322 
ruber, 310 

description of, 310 
treatment of, 311 
Lientery, 670 

Limbs, contractions of, in disseminated 

sclerosis, 908 
Lipoma, 74 

Lister, on antiseptic treatment, 257 

on septicaemia, 143 
Liveing, on leprosy, 258 

on megrim, 989 
Liver, abscess of (see Hepatitis), 682 
adenoid cancer of, 695 
anatomical relation of, 675 
carcinoma of, 694 
cavernous tumors of, 694 
cirrhosis of (see Cirrhosis of), 687 
congestion of (see Congestion of), 691 
cysts of, 694 
diseases of, 675 et seq. 
drunkard's, 687 
fatty, 702 

causation of, 702 

morbid anatomy of, 702 

symptoms of, 702 

treatment of, 703 
hob-nail, 687 
hydatids of, 698 

morbid anatomy of, 698 

symptoms and progress of, 698 

treatment of, 700 
in ague, 270 

inflammation of (see Hepatitis), 681 
jaundice in disease of (see Jaundice), 
678 

lardaceous, 763 

causation of, 763 

morbid anatomy of, 763 

symptoms of, 763 

treatment of, 764 
lymphadenoma of, 696 
malignant growths of, 694 

morbid anatomy of, 694 

symptoms and progress of, 691 

treatment of, 698 
• melanotic sarcoma of, 696 
morbid growths of, 692 et seq. 
parasitic disease of, 698 
pathology (general) of, 677 
physiology (general) of, 676 
pulsation of, in heart-disease, 447 
pyaemic affection of, 251 
sarcoma of, 695 
syphilis of. 693 

morbid anatomy of, 245, 693 

symptoms of, 693 

treatment of, 694 
tubercle of, 692 



1064 



INDEX. 



Liver, yellow atrophy of (see Malignant 

Jaundice), 712 
Liver-ducts (see Hepatic ducts), 681, 708 
Local paralyses, 991 
Lockjaw (see Tetanus), 977 
Locomotion, organs of, diseases of, 783 et 

seq. 

Locomotor ataxy (see Tabes Dorsalis), 896 
Lousiness (see Phthiriasis), 316 
Lumbago, 784 

Lungs, anatomical relations of, 329 
in cholera, 230 

cirrhosis of (see Cirrhosis of Lungs), 

385 

collapse of (see Pulmonary Collapse), 
419 

congestion of (see Congestion of Re- 
spiratory Organs), 417 
emphysema of (see Emphysema), 412 
hemorrhage from (see Hemorrhage of 

Respiratory Organs), 421 
hydatids of, 408 

morbid anatomy, 408 
symptoms of, 407 
treatment of, 410 
inflammation of (see Pneumonia), 368 
morbid growths o< (see Morbid Growths 

of Respiratory Organs), 404 
cederna of (see Dropsy of Respiratory 

Organs). 418 
pysemie affection of, 250 
syphilitic disease of, 245 

(See also Syphilitic Diseases of Re- 
spiratory Organs), 402 
tubercle of (see Tubercle of Respiratory 
Organs), 389 
Lupus. 306 

causation of, 306 
description of, 306 
erythematosus, 307 
exedens, 307 
non-exedens, 307 
pustular, 308 
treatment of, 308 
tubercular, 307 
Luys and Voisin on epilepsy, 961 
Lymphadenoma, 79 

of abdominal lymphatics, 621 
of bowels, 621 

of kidney (see Kidney, Morbid Growths 
of), 753 

of liver (see Liver, Lymphadenoma of), 
696 

of peritoneum, 622 
of stomach, 622 
Lymphangioma, 79 

Lymphatic glands of abdomen, malignant 
disease of, 624 
tubercle of, 615 
in glanders, affection of, 237 
in leprosy, affection of, 255 
in plague, enlargement of, 189 
in syphilis, affection of, 240, 245 
scrofulous, 79 
tumors, 78 

vessels, obstruction and dilatation of, 
528 

morbid anatomy of, 528 
symptoms of, 528 
treatment of, 529 



mphatics, diseases of, 524 et seq. 
in elephantiasis, 313 
in elephantiasis lymphangiectodes, 
313 

inflammation of, 524 
causation of, 524 
morbid anatomy of, 524 
symptoms and progress of, 525 
treatment of, 525 

morbid growths of, 526 
in mediastinum, 526 
symptoms and progress of, 526 
treatment of, 526 

tubercle of, 525 

morbid anatomy of, 525 
symptoms and progress of, 526 
treatment of, 526. 
Lymphoma, 79 



MACKENZIE, M., on chronic laryngitis, 
358 

on laryngeal phthisis, 358 
on paralysis of larynx, 427 
on stricture of oesophagus, 577 
on syphilitic disease of larynx, 402 
Maclean, on ague, 270 

on hepatic abscess, 6S3 
Macula, meaning of term, 275 
Macula?, Willan's 8th order, 275 
Magnan on delirium tremens, 548' 
Mahomed on blood in urine, 729 
Maintenance in health, 49 
Malaria, 45, 263 
Malformation ofheart, 483 
causation of, 483 
morbid anatomy of, 483 
symptoms and progress of, 484 
treatment of, 485 
Malignant, as applied to tumors, 88 
cholera (see Epidemic Cholera), 222 
diphtheria, 265 

growths (see Morbid Growths) 

of bladder, 775 

of bowels, 619 

of brain and cord, 916 

of heart and pericardium, 467 

of kidney, 753 

of larynx, 4 04 

of liver, 692 

of lungs and pleurre. 405 

of lymphatic glands, 526, 618 

of mediastinum, 526 

of mouth, fauces, etc., 570 

of oesophagus, 572 

of ovaries, 777 

of pancreas, 715 

of peritoneum, 619 

of spleen, 522 

of stomach, 619 

of supra-renal capsules, 519 

of thyroid body, 508 

of uterus, 777 
jaundice, 713 

causation of, 713 

definition of, 713 

morbid anatomy of, 714 

symptoms and progress of 713 

treatment of, 715 
scarlet fever, 164 



INDEX. 



1065 



Malignant smallpox, 173 

Mammae, affection of, in hysteria, 972 

in mumps, 154 
Mania, 1025 

epileptica, 960 
in hysteria, 967 
Marce, definition of insanity, 1010 
Marochetti on hydrophobia, 236 
Marson on smallpox, 169 et seq. 
Maudsley, definition of insanity, 1010 
Measles, 155 

causation of, 155 
causes of death in, 157 
complications and sequelae of, 157 
definition of, 155 
duration of, 157 
in adults, 157 
incubation of, 155 
morbid anatomy of, 158 
symptoms and progress of, 155 
treatment of, 158 
varieties of, 157 
Mechanical causes of disease, 43 
derangements, 103, 104 
compression, 104- 
contraction, 104 
dilatation, 105 
displacement, 104 
impaction, 105 

rupture and extravasation, 107 
Mediastinal tumors, 527 

morbid anatomy of, 527 
symptoms and progress of, 527 
treatment of, 528 
Megrim, 986 

aphasia in, 1136 
causation of, 986 
definition of, 986 
drowsiness in, 988 
duration of, 988 
headache in, 987 
hearing, affection of, in, 987 
mental affections in, 987 
paralysis in, 987 
pathology of, 986 
sight, affection of, in, 987 
symptoms and progress of, 986 
treatment of, 986 
Meigs and Pepper on cholera infantum, 673 
Melaena {see Hemorrhage of Stomach and 

Bowels), 658 
Melanaeinia in ague, 270, 271 
Melancholia, 1021 

varieties of, 1023 

with destructive tendencies, 1024 
with excitement, 1025 
with hypochondriasis, 1023 
with stupor, 1024 
Melanuric bilious fever, 766 

M. Berenger Feraud on, 766 
Melasma Addisonnii {see Addison's Disease) , 
515 

Melassez on Alopecia areata {note), 327 
Melsens on treatment of lead-poisoning, 554 
Membranous croup {see Diphtheria), 200 
Meniere's disease, 989 

causation of, 989 

definition of, 989 

pathology of, 990 

symptoms and progress of, 990 



Meniere's disease, treatment of, 991 
Meningeal hemorrhage {see Cerebral Hemor- 
rhage), 926 
Meningitis, 200, 868 
causation of, 868 

cerebro-spinal {see Cerebro spinal Fe- 
ver), 198 
morbid anatomy of, 868 
cerebral, 868 

spinal, 870 &/ 
symptoms and progress of, 870 
cerebral, 870 
spinal, 876 
treatment of. 875 
tubercular, 868 

symptoms and progress of, 870 
treatment of, 875 
Mental disturbance, pathology of, 856 
Mercurial poisoning, chronic, 555 
causation of, 355 
morbid anatomy of, 556 
symptoms and progress of, 555 
treatment of, 556 
Mercurialism, 555 

Mesenteric glands, affection of, in enteric 

fever, 219 
Metallic breathing, 348 

tinkling, 348 
Metallo-therapeutics in hysteria, 975 
Metritis, 776 

causation of, 776 

morbid anatomy o", 776 

symptoms of, 776 
Meynert on anatomy of brain and cord, 815 
et seq. 

Miasm, as cause of ague, 263 
Michaud on vertebral caries 860 
Micrococci in enteric fever, 220 
Microsporon Audouini, 327 

furfur, 325 
Migraine {see Megrim), 986 
Migration of leucocytes, 52, 63 
Miliaria, 297 

Millstone-grinders' phthisis, 387 
Miners' phthisis, 387 
Mitchell, S Weir, on glossy skin, 846 
Mitral valve disease, 443 
diagnosis of. 453 
effects of on heart, 446 
obstructive 443 
prognosis of. 456 
regurgitant, 443 
treatment of, 457 
Moissonet on puncture of hydatid cysts, 700 
Mollities ossium, 808 

causation of, 808 
definition of, 808 
morbid anatomy of, 808 
pathology of, 808 
symptoms and progress of, 808 
treatment of, 808 
Molluscum contagiosum, 315 
causation of, 3 1 5 
description of, 315 
treatment of, 315 
Monomania, 1029 

Montague, Lady M. W., on inoculation of 

smallpox, 168 
Morbid growth, 51 

dyscrasia, primary in, 56 



1066 



INDEX. 



Morbid growth, dyscrasia, secondary in, 57 
generalization of, 53 
limitation of to certain tissues, 55 
local spread of, 53 
of cells, 51 
Morbid growths (see Tumors), 71 
of bowels, 618, 623 
of brain, 916 

convulsions and spasms in, 922 
hemianesthesia in, 921 
hemiplegia in, 921 
intellectual and emotional dis- 
orders in, 922 
local anesthesia in, 921 
local paralyses in, 921 
morbid anatomy of, 917 
obstruction of the venous sinuses 
in, 923 

symptoms and progress of, 920 
treatment of, 929 
vertigo in, 920 
vomiting in, 920 
of digestive organs, 618 
malignant, 619 

morbid anatomy of, 619 
symptoms and progress of, 622 
treatment of, 625 
non-malignant, 618 
polypoid, 618 
villous, 618 
of heart and pericardium, 467 
of kidney (see Kidney, Morbid 

Growths of), 753 
of larynx, 404 

morbid anatomy of, 404 
symptoms of, 404 
treatment of, 404 
of liver, 602 

malignant ,and non-malignant, 694 
morbid anatomy of, 694 
symptoms and progress of, 696 
treatment of, 698 
of lungs and pleurae, 405 

malignant and non-malignant, 405 
morbid anatomy of, 405 
symptoms and progress of, 406 
treatment of, 408 
of lymphatics (see Lymphatics, Mor- 
bid Growths of), 526 
of mouth, fauces, &c , 570 
of oesophagus (see Oesophagus, Mor- 
bid Growths of), 574 
of pancreas, 716 
of peritoneum, 618, 624 
of respiratory organs, 404 
of spinal cord, 916 

morbid anatomy of, 917 
symptoms and progress of, 924 
treatment of, 926 
of spleen (see Spleen, Tumors of), 
522 

of stomach, 618, 622 

of supra renal capsules, 519 

of thyroid body, 508 

of urinary bladder, 775 

of uterus and ovaries, 778 
Morbilli (see Measles), 155 
Morbus comitialis (see Epilepsy), 951 
Morphoea (see Scleroderma), 311 
Mortification (see Gangrene) 



Mosquitoes, 320 

Mouth, affection of, in diphtheria, 204 

diseases of, 557 et seq- 

syphilitic disease of, 570 

tubercle of, 570 
Moxon on insular sclerosis, 905 
Mucous degeneration, 96 

tubercles in syphilis, 241 

tumors, 74 
Miiller, J., on classification of tumors, 7 
Multiple embolism, 507 

sclerosis (see Sclerosis, Disseminate 
905 
Mumps, 153 

causation of, 153 

complications and sequelae of, 154 
definition of, 153 
diagnosis of 154 
incubation of, 153 
inflammation of breast in, 154 

of testicle in, 154 
morbid anatomy of, 154 
symptoms and progress of, 153 
treatment of, 154 
Murchison on biliary acids in urine, 678 
on cholesterine in urine, 731 
on enteric fever, 210 et seq. 
on gout, cause of, 798 
on hydatid cysts, puncture of, 700. 
on jaundice from constipation, 678 
on liver, functional disturbance 
677 

physiology of, 676 
on reabsorption of bile, 713 
on relapsing fever, 190 et seq. 
on typhus, 183 et seq. 
Murmurs, endocardial, 450 
aortic obstructive, 452 

regurgitant, 452 
hseinic, 455 
mechanism of, 450 
mitral obstruction, 453 

regurgitant, 453 
prge systolic, 454 
pulmonic obstructive, 453 

regurgitant, 453 
quality of, 450 
tricuspid obstructive, 454 
regurgitant, 454 
pericardial, 449 
venous, 451 
Muscles, condition of, in paralysis, 835 
contractility, 836 
faradic sensibility, 836 
irritability, 836 
nutrition, 836 
reflex action, 836 
tone, 835 

rigidity of, in cerebral hemorrha 
931, 932 
in disseminated sclerosis, 908 
in paralysis agitans, 912 
in tetanus, 977 
Muscular atrophy, progressive, 889 
causation of, 889 
definition of, 889 
morbid anatomy of, 890 
symptoms and progress of, 890 
treatment of, 892 
tumors, 77 



INDEX. 



1067 



Musculo-spiral nerve, paralysis of, 1000 

treaiment of, 1000 
Myelitis, 876 

causation of, 876 

morbid anatomy of, 878 

symptoms and progress of, 880 

treatment of, 882 
Myeloid tumors, 90 
Myocarditis, 459, 463 

causation of, 463 

morbid anatomy of, 464 

symptoms and progress of, 465 

treatment of, 466 
Myoma, 77 

of ovaries, 777 

of uterus, 777 
symptoms of, 777 
Myxoedema, 514 

causation of, 514 

definition of, 514 

history of, 514 

morbid anatomy of, 515 

symptoms and progress of, 515 
Myxoma., 74 

of brain and cord (see Morbid Growths 
of Brain and Cord), 916, 918 

cystic, 75 

enchondromatous, 75 
erectile, 75 
lipomatous, 75 



"V^iEMATODA, general account of, 631 
IN Nails, affection of, in favus, 525 

in tinea tonsurans, 322 
Narcotics in the treatment of insanity, 1044 
Naunyn on haemic murmurs, 455 
Nausea in dyspepsia, 663 
Navel, position of in abdominal disease, 780 
Necrosis, 95, 101 

Nephritis, acute, albuminous, degenerative, 
or tubal, 740 
chronic, interstitial, 746 

parenchymatous, or tubal, 744 
circumscribed (see Suppurative), 739 
suppurative, 739 

morbid anatomy of, 739 
symptoms of, 740 
treatment of, 740 
Nerve-anaesthesia, 839 

paralysis, 834 
Nerve-lesions, central consequences of, 849 

reflex consequences of, 849 
Nerves, affection of, in leprosy, 260, 261 
Nervous diseases, ascending lesions in, 849 
collateral lesions in, 848 
descending lesions in, 848 
influence of, over nutrition, 843 
functions in health, 50 
Nervous system, anatomy and physiology 
of, 810 
arachnoid cavity, 810 
arteries, 827 

cerebellum and peduncles, 815 
cerebral hemispheres, 811 
cerebro-spinal nerves, 817 
convolutions, 813 
dura mater, 810 
fissures, 811 
functions of, 821 



Nervous system, anatomy and physiology of, 
ganglia at base of brain, 814 
medulla oblongata, 816 
membranes of brain and cord, 810 
pia mater, 811 

relation between different parts of, 
810 

spinal cord, 816 
sub-arachnoid space, 811 
sulci, 812 

sympathetic system, 827 
veins, 830 
ventricles, 811 
diseases of, 810 et seq. 
introduction to, 810 
pathology of, 831 
amnesia. 85 L 
anaesthesia, 837 
aphasia 851 
aphemia, 851 

convulsions and spasms, 840 

dysesthesia, 84 2 

emotional disturbance, 856 

headache, 849 

hypereesthesia, 842 

mental disturbance, 856 

nutritive lesions, 843 

paralysis and paresis, 831 

vertigo, 850 
tumors, neuroma, 76 
Nettle-rash (see Urticaria), 284, 287 
Neuralgia, 1003 

anaesthesia in, 1005 
causation of, 1003 
convulsive movements in, 1005 
definition of, 1003 

dilatation of vessels in connection with, 
1006 

epileptiform (see Tic Douloureux), 1007 
in zona, 299 

nutritive lesions in, 1005 
of heart (see Angina Pectoris), 480 
painful spots in, 1004 
symptoms and progress of, 1004 
treatment of, 1007 

Neuritis, optic, 863, 873, 880, 922 

Neuroma, 77 

Niemeyer on diffusion of tubercle, 87 

Nodes, syphilitic, 242, 245 

Noli me tangere (see Lupus), 306 

Noma, 563 

causation of, 563 
morbid anatomy of, 563 
symptoms and progress of, 563 
treatment of, 564 

Nose, affection of, in diphtheria, 205 
in glanders, 236 
in syphilis, 244, 246 

Nummulated sputum, 334 

Nutmeg liver (see Congestion of), 691 

Nutrition of paralyzed muscles, 836 

influence of nervous diseases over, 843 
of bones, influence of nervous diseases 
over, 845 

of joints, influence of nervous diseases 
over, 845 

of muscles, influence of nervous dis- 
eases over, 843 

of skin, influence of nervous diseases 
over, 845 



1068 



INDEX. 



Nutrition of viscera, influence of nervous dis- 
eases over, 847 
Nutritive lesions in neuralgia, 1005 
Nystagmus in disease of cerebellum, 824 
in disseminated sclerosis, 907 



OBERMEIER on contagium of relapsing 
fever, 141 

Obstruction of arteries (see Thrombosis and 
Embolism), 500 
of bowels (see Bowels, Obstruction of), 

640 

of cerebral arteries (see Cerebral Arte- 
ries, Obstruction of), 934 

of hepatic ducts (see Hepatic Ducts, 
Obstruction of), 708 

of lymphatic vessels (see Lymphatic 
Vessels, Obstruction of), 528 

of oesophagus (see OEsophagus, Chronic 
Affections of), 572 

of stomach (see Stomach, Obstruction 
of), 638 

of urinary passages (see Urine, Suppres 

sion of), 772 
of veins (see Thrombosis and Embolism) , 

' 500 

Occlusion (see Obstruction) 
Occupation, as cause of disease, 39 
Oculo-motor nerves, paralysis of, 990 
causation of, 991 
symptoms and diagnosis of, 991 
treatment of, 995 
Odorous matters in urine, 724 
CEdema (see Dropsy), 109 

of larynx (see Dropsy of Respiratory 

Organs), 418 
of lungs (see Dropsy of Respiratory Or- 
gans), 418 

Oertel on the cause of diphtheria, 202, 208 
Oesophagus, anatomical relations of, 571 

diseases of, 571 et seq. 

chronic and obstructive affections of, 
572 

auscultation in, 576 

dysphagia in, 575 

obstruction in, 575 

symptoms of, 575 

treatment of, 577 
dilatation of, 574 
diphtherial affection of, 204 
implication of, from without, 574 
inflammation of, 572 

causation of, 572 

morbid anatomy of, 572 

symptoms of, 572 
morbid growths of, 573 
paralysis of, 573 
spasm of, 573 
ulceration of, 571 
Offenburg on cure of hydrophobia, 235 
Oidium albicans in thrush, 560 
Oophoritis, 776 

causation of, 776 
morbid anatomy of, 776 
symptoms of, 776 
Ophthalmia in relapsing fever, 192 
in smallpox, 171 
in trifacial palsy, 995 
Opisthotonos, 979 



Ord on gout, 799 

on temperature in pseudo-hypertrophic 
paralysis, 916 

on indigo calculus, 733 

on myxoedema, 513 
Orfila, L., on lead in system, 553 
Organization in inflammation, 67 
Orthopnoea (see Dyspnoea), 332 
Osseous tumors, 76 

Osteo-malacia (see Mollities Ossium), 809 
Osteoma, 76 

compact, 76 

ivory, 76 

spongy, 76 

Otitis (see Inflammation of Dura Mater and 

Encephalitis), 860, 876 
Ovarian dropsy (see Ovaries, Cysts of), 778 
Ovaries, cysts of, 778 

causation of, 778 
morbid anatomy of, 778 
symptoms and progress of, 780 
treatment of, 781 
diseases of, 776 

inflammation of (see Oophoritis), 776 
malignant disease of, 778 

symptoms of, 777 
myomata of, 777 

symptoms of, 777 
tubercle of, 778 
Ovary, effects of pressure on, in hysteria, 
969, 974 

hyperaesthesia of, in hysteria, 968 
Oxalate of lime, 727 
calculi. 732 
Oxvuris vermicularis (see Thread-Worm), 

633 
Ozaena, 569 

causation of, 569 

chloral in, 570 

symptoms of, 570 

treatment of, 570 



PACHYDERMIA (see Elephantiasis), 313 
Pachymeningitis (see Dura Mater, In- 
flammation of), 860 
cerebral, 860, 864 
spinal, 861, 866 
Paget on glossy shin, 846 
on myeloid tumors, 90 
on recurrent fibroid tumors, 89 
Pain (see Hyperaesthesia), 842 
Palmellas, as cause of ague, 264 
Palpitation, 477 

Palsy, glosso-labio-laryngeal (see Glosso- 
labio-laryngeal Palsy), 902 
lead (see Lead-poisoning, Chronic), 550 
wasting (see Muscular Atrophy, Pro 
gressive), 889 

(See also Paresis and Paralysis) 
Pancreas, abscess of, 716 
calculi of, 716 
cysts of, 716 
diseases of, 715 et seq 

introduction to, 715 
ducts of, dilatation of, 716 

obstruction of, 716 
hyperemia of, 716 
inflammation of, 716 
morbid growths of, 716 



INI 

I Pancreas, symptoms of diseases of, 717 
treatment of diseases of, 717 
Papula, meaning of term, 275 
Papulse, Willan's first order, 276 
Paracentesis abdominis, 657 686, 700 

thoracis, 384, 424 
Paralysis, meaning of term, 831 
agitans, 910 

causation of, 911 
j definition of, 910 

morbid anatomy of, 911 
symptoms and progress of, 911 
treatment of, 9 14 
bulbar, pathology of, 832 
in cerebral hemorrhoge, 929 et seq. 
cerebral, pathology of, 831 
in chorea, 948 

condition of muscles in (see Muscles, 

Condition of, etc.), 835 
in diphtheria, 207 
in disseminated sclerosis, 936 et seq. 
essential Paralysis, Spinal Infantile, 

884 

of fifth nerve (see Fifth Pair, Paralysis, 

of), 995 
general pathology of, 831 
in hysteria, 969 
/ infantile [see Paralysis, Spinal Infan- 
tile), 884 
laryngeal, 424 

involving arytenoideus, 427 

crico-arytenoidei laterales, 426 
crico-arytenoidei postici, 426 
pneumogastrics, 426 
recurrent laryngeals, 425 
superior laryngeals, 425 
thyro-arytenoidei, 427 
treatment of, 427 
local, 991 
functional, 1001 
in tumors of brain, 920 
in megrim, 9S7 
of musculo-spiral nerve, 1000 

treatment of, 1001 
of nerves, pathology of, 8^4 
of oculo-motor nerves (see Oculo- Motor 

Nerves, Paralysis of), 990 
of oesophagus, 574 
pathology of, 831 

of portio dura (see Portio Dura, Paral- 
ysis of), 996 
pseudo hypertrophic, 914 

causation of, 914 

definition of, 914 

morbid anatomy of, 914 

pathology of, 917 

symptoms and progress of, 914 

treatment of, 916 
spinal, adult, 887 

general, 888 

causation of, 888 
definition of, 888 
morbid anatomy of, 888 
symptoms and progress of, 888 
treatment of, 889 

infantile, 884 
causation of, 884 
definition of, 884 
morbid anatomy of, 834 
symptoms and progress of, 885 



ex. 1069 

Paralysis, infantile, treatment of, 8S7 
pathology of, 831 
of spinal nerves (see Spinal Nerves, 

Paralysis of), 999 
unilateral, pathology of, 831 
Paraplegia in alcoholic poisoning, 548 
in hysteria, 969 
pathology of, 833 

(See also various diseases of spinal 
cord) 

Parasites as causes of disease, 45 
Parasitic affections of brain, 916, 919, 924 

of digestive organs (see Different 
Worms), 624 et seq. 

of heart, 470 

of kidney, 754 

of liver, 697 

of respiratory organs (see Hydatids), 
408 

of skin, 314 et seq. 
Paresis in disseminated sclerosis, 936 

pathology of, 831 
Parkes on blood in purpura, 536 

on cause of ague, 263, 264 

on dysentery, 603 

on fever, 116 

on urea in urine in enteric fever, 115 

Parotitis (see Mumps), 153 

Parry, Dr. John S. , on craniotabes, 806 

Passive congestion, 108 

Pathology, definition of, 33 
general, part I., 33 et seq. 
special, part II., 137 et seq. 

Pavy on diabetes, 771 

Peacock on cyanosis, 482 
on intussusception, 649 
on malformation of heart, 485 
on measurement of orifices of heart, 
434 

on prognosis of cardiac diseases, 457 
Pectoriloquy, 347 
Fediculis, capitis, 316 

pubis, 317 

tabescentium, 317 

vestimenti, 316 
Pelvic connective tissue, diseases of, 781 

organs, diseases of, 774 et seq. 

peritoneum, diseases of, 781 
Pemphigus (see Herpes), 298 

acute, 301 

causation of, 298 

chronic, 301 

description of, 298 

foliaceous, 301 

gangrasnosus (see Rupia), 302 
solitarius, 301 
treatment of, 301 
vulgaris, 30 I 
Penicillium in urine, 732 
Pentastoma denticulatum, 755 
Percussion, 340 

abdominal, 580 
abnormal, 341 

bruit de pot fele, 344 

dulness, 341 

resistance, 344 

resonance, 342 

tympanitic resonance, 342 
normal, 34 1 

dulness, 341 



1070 



INDEX. 



Percussion, normal, resonance, 341 
Pereira, on removal of lead by skin, 553, 
554 

Periarteritis, 486 

causation of, 486 

morbid anatomy of, 486 

symptoms of, 487 
Pericarditis, 459 

causation of, 459 

morbid anatomy of, 459 

suppurative, 459 

symptoms and progress of, 461 

treatment of, 466 
Pericardium, adhesion of, diagnosis of, 451 

dropsy of, 476 

effusion into, diagnosis of, 451 

effect on form of pericardium, 448 
prognosis of, 455 
treatment of, 457 

hemorrhage into, 475 

inflammation of {see Pericarditis), 459 

syphilitic disease of, 468 

tubercle of, 468 
Perihepatitis, 690 
Periproctitis, 599, 601 

causation of, 601 

morbid anatomy x of, 601 

symptoms and prognosis of, 602 

treatment of, 602 
Peritoneum, colloid cancer of, 619 

dropsy of {see Ascites), 656 

encephaloid cancer of, 620 

inflammation of {see Peritonitis), 608 

lymphadenoma of, 620 

malignant disease of (symptoms), 624 
treatment of, 625 

sarcoma of, 621 

scirrhous cancer of, 619 

tubercle of, 614 

morbid anatomy of, 614 
symptoms and progress of, 616 
treatment of, 618 
Peritonitis. 608 

acute, 610 

adhesive, 613 

causation of, 608 

diagnosis of, 613 

in enteric fever, 216 

morbid anatomy of, 608 

perforative, 611 

puerperal, 611 

suppurative, 609 

symptoms and progress of, 610 

treatment of, 613 
Perityphlitis {see Typhlitis), 599 
Pernicious anaemia, 533 
Personal peculiarities as causes of disease, 
38 

Pertussis {see Hooping cough), 149 
Pestilentia {see Plague), 188 
Petechias, meaning of terra, 274 
Peter on inoculation of diphtheria, 202 
Petit mal {see Epilepsy), 9ol 
Pettenkofer on causes of cholera, 223 
on detection of biliary acids, 729 
Peyer's glands, affection of, in cholera, 229 

in enteric fever, 217 

in phthisis, 615 
Pharynx, abscess behind {see Retro-Pharyn- 
geal Abscess), 569 



Phlebitis, 498 

causation of, 498 

morbid anatomy of, 498 

symptoms of, 499 
Phlegmasia alba dolens, 504 

treatment of, 504 
Phthiriasis, 316 

causation and description of, 316 

treatment of, 317 
Phthisis, abdominal, 614 

chronic pneumonic, 391 

fibroid {see Cirrhosis of Lungs), 384 

inflammatory origin of, 393 

laryngeal, 356, 359 

{See also Respiratory Organs, Tubercle 
of), 389 

miners', millstone grinders', colliers', 

flax-dressers', etc , 388 
pulmonary {see Respiratory Organs, 

Tubercle of), 389 
Physaliphores, 91 

Physiological processes in disease, 51 
in health, 46 
tissues, 47 

Pia mater, inflammation of {see Meningitis), 

868 

tubercle of {see Meningitis), i w 68 
Pictonum colica {see Lead-poisoning, Chron- 
ic) , 550 
Pigmentary degeneration. 99 
Piorry on hydatid thrill, 699 
Pityriasis, 284, 285 
rubra, 289, 290 
description of, 291 
treatment of, 291 
simplex, 285 

versicolor {see Tinea Versicolor), 324 
Plague, 188 

causation of, 188 

definition of, 188 

duration of, 189 

history of, 188 

morbid anatomy of, 189 

mortality of, 189 

resemblance of, to typhus, 188 

symptoms and progress of, 188 

treatment of, 189 
Plastic bronchitis, 365 

sputum, 335 
Pleurae, air in {see Pneumothorax), 423 

anatomical relations of, 330 

dropsy of {see Hydrothorax), 418 
detection of, 3 4 

inflammation of {see Pleurisy), 376 

m rbid growths of, 404 

tubercle of {see Respiratory Organs, 
Tubercle of), 389 
Pleurisy, 376 

causation of, 377 

causes of death in, 381 

invasion of, 380 

morbid anatomy of, 378 

suppurative, 381 

symptoms and progress of, 380 

treatment of, 383 
Pleuritis {see Pleurisy), 376 
Pleurosthotonos, 979 
Plica polonica, 316 

Plumbisra {see Lead-poisoning, Chronic), 

550 



INDEX. 



1071 



Pneumonia, 368 

catarrhal, 368 

causation of, 368 

causes of death in, 372 

chronic (see Cirrhosis), 384 

complications of, 371 

croupous, 368 

idiopathic, 372 

lobar, 369 

lobular, 369, 371 

(See also Diphtheria, 208) 

morbid anatomy of, 368 

mortality of, 375 

symptoms and progress of, 372 

treatment of, 375 
Pneumothorax, 424 

causation of, 424 

morbid anatomy of, 424 

symptoms and progress of, 424 

treatment of, 424 
Podagra (see Gout), 793 
Poland on tetanus, 977, 979 
Pompholyx (see Pemphigus), 298 
Poore on electricity, 858 

on writer's cramp, 1003 
Porrigo decalvans (see Alopecia Areata), 
325 

favosa (see Tinea Favosa), 323 
larvalis (see Impetigo), 296 
lupinosa (see Tinea Favosa), 323 
scutulata (see Tinea Tonsurans), 321 
Portio dura, paralysis of, 996 
causation of, 996 
contraction of muscles after, 997 
double, 997 
epiphora in, 997 
pain in connection with, 997 
paralysis of soft palate in, 998 
symptoms and diagnosis of, 997 
treatment of, 999 
Praecordiuin, change of area of dulness of, 
448 
form of, 448 
increased resistance of, 449 
Predisposing cause, 36, 37 
Premonitory diarrhoea of epidemic cholera, 
226 

Previous disease, as cause of disease, 39 
Priapism in myelitis and spinal meningitis, 
875, 881 

Privation as cause of disease, 39 
Prognosis (see different diseases) 
Progressive muscular atrophy (see Muscular 

Atrophy, Progressive), 889 
Prophylactic treatment, 128 

of fevers, 144 
Prophylaxis, 128 
Protoplasm in health, 46 

vital properties of, 48 
Prout, on chyluria, 762, 763 

on the treatment of gall-stones, 708 
Proximate cause, 36 
Prurigo, 327 

description of, 327 
treatment of, 328 

{See also Phthiriasis, 316) 
Psammoma, 90 , 
Pseudo-bypertrophic paralysis (see Paraly- 
sis, pseudo-hypertrophic), 914 
Pseudo-leukaemia, 82 



Psoriasis, 289 

causation of, 289 
description of, 290 
diffusa, 290 
guttata, 290 
inveterata, 290 
lepra alphoides (alphos), 290 
gyrata, 290 
vulgaris, 290 
treatment of, 291 
Puerperal fever (see Pyaemia, Peritonitis, 

and Scarlet Fever) 
Pulex penetrans, 320 

Pulmonary apoplexy (see Hemorrhage of 
Respiratory Organs), 421 
collapse, 419 

causation and morbid anatomy of, 
419 

symptoms and progress of, 421 
treatment of, 421 
varieties of, 420 
dropsy, 109, 418 

phthisis (see Respiratory Organs, Tu- 
bercle of), 389 
tubercle, 389 
Pulmonic valve disease, causes of, 443 
diagnosis of, 453 
effects of, on heart, 446 
prognosis of, 456 
treatment of, 457 
Pulsation, cardiac, in heart disease, 449 
varieties of, 449 
hepatic in heart disease, 447 
Pulse, 437 

trace, 438, 439 
varieties of, in health, 440 
in heart disease, 443 
in aortic valve disease, 452 
as to force, 444 
as to frequency, 444 
in mitral valve disease, 454 
as to rhythm, 444 
Purpura, 535 

causation of, 535 
definition of, 535 
hemorrhagic, 536 
morbid anatomy of, 537 
simplex, 536 

symptoms and progress of, 536 

treatment of, 537 

urticans, 286 
Purring tremor, 449 
Pus, 65 

in urine, liquor potass® test for, 731 
Pustulae, Willan's fifth order, 276 
Pustules, meaning of term, 277 
Pyaemia, 250 

bacteria in blood in, 253 

blood, condition of, in, 252 

bone and joint-affection in, 251 

brain-affection, 251 

causation of, 250 

definition of, 250 

diagnosis of, 256 

embolism and thrombosis in, 252 

heart, affection of, in, 251 

kidney, affection of, in, 252 

liver, affection of, in, 252 

lungs, affection of, in, 251 

morbid anatomy and pathology of, 251 



1072 



INDEX. 



Pyaemia, mortality of, 256 

spleen, affection of, in, 251 
symptoms and progress of, 254 
treatment of, 256 

Pyelitis, 736 

causation of, 736 
morbid anatomy of, 736 
suppurative, 737, 738 
symptoms and progress of, 737 
treatment of, 738 

Pyrosis, 664 



QUAIN, R., on hypertrophy of heart in 
renal disease. 734 
Quartan ague, 267 
Quinine in ague, 272 
Quinsy, acute, 566 

causation of, 566 
morbid anatomy of, 566 
symptoms and progress of, 567 
treatment of, 568 
chronic, 568 

symptoms and progress of, 568 
treatment of, 569 
Quotidian ague, 267 



RABIES (see Hydrophobia), 233 
Rachitis (see Rickets), 801 
Radcliffe, N., on cerebro-spinal fever, 198 

on cholera, 224 
Rainey, on calcareous deposit, 101 

on emphysema, 415 
Rales, 352 

crepitant, of oedema, 352 
Ranke, on heat of body, 113 
Ransom, on thread-worms, 632 
Rash (exanthema), 275 
Rayer on diabetes insipidus, 772 
Recamier on hemiplegia in cerebral soften- 
ing, 936 

Rectum, ulceration of (see Periproctitis), 
597 

Recurrent fibroid tumors, 89 

Red hepatization of lung, 369, 571 

induration of lung, 386 
Reduplication of heart's sounds, 451, 734 
Reflex action in paralyzed muscles, 836 
Relapsing fever, 190 

abortion in, 192 

causation of, 190 

causes of death in, 192 

convalescence protracted in, 192 

definition of, 190 

history of, 190 

incubation of, 191 

morbid anatomy of, 192 

mortality in, 192 

sequelae of, 192 

spirillum in blood in, 141 

symptoms and progress of, 191 

treatment of, 193 
Remedial treatment (see Therapeutical), 130 
Remittent fever (see Ague), 263, 265 
Renal calculi or concretions, 732, 757 
dropsy, 109 

disease (see Kidneys, diseases of), 718 
et seq. 
Repair, 68 



Reproductive organs, affection of, in hys- 
teria, 971 
Respiration, pathology of, 331 

dyspnoea, 332 
Respiratory organs, diseases of, 329 et seq. 
in glanders, 237 
in leprosy, 260, 262 
in pyaemia, 250 
tubercle of, 389 

causation of, 385 
causes of death in, 400 
morbid anatomy, 385 
morbid anatomy of cheesy or yel- 
low, 390 

morbid anatomy of gray or mil- 
iary, 389 
morbid anatomy of laryngeal, 

389 

morbid anatomy of pleural, 393 
morbid anatomy of pulmonary, 

389 

symptoms and progress, 394 
symptoms and progress of acute 

phthisis, 399 
symptoms and progress of chronic 

phthisis, 398 
symptoms and progress of pleural 

tubercle, 398 
treatment of, 400 
Retina, anaemia of, in epilepsy, 959 
Retinal hemorrhage in renal disease, 735 
Retro-pharyngeal abscess, 569 
causation of, 569 
symptoms and progress of, 569 
treatment of, 569 
Reynolds, K., on epilepsy, 951 et seq. 

on hysterical paralysis, 975 
Rheumatic fever (see Rheumatism), 783 
Rheumatism, 783 

causation of, 783 
chorea in relation with, 944 
complications of, 786 
definition of, 783 

deltoid (see Deltoid Rheumatism), 1000 

heart disease in, 786 

lumbago, 784 

morbid anatomy of, 783 

pathology of, 788 

scarlet fever in relation with, 165 

sciatica, 784 

symptoms and progress of, 784 
torticollis, 784 
treatment of, 789 
Rheumatoid arthritis, 791 
causation of, 791 
definition of, 791 
morbid anatomy of, 791 
pathology of, 793 
symptoms and progress of, 792 
treatment of, 793 
Rhonchus, 353 
Rhythmical movements, 976 
treatment of, 977 
tremors in disseminated sclerosis, 906 
in mercurialism, 554 
in paralysis agitans, 911 
Richardson, on tetanus, 980 
Rickets, 801 

causation of, 802 
definition of, 801 



INDEX. 



1073 



Rickets, morbid anatomy, 802 

pathology of, 802 

symptoms and progress of, 805 

treatment of, 807 
Ricord on syphilis, 239 

Rigidity, muscular, in lateral sclerosis, 895 
in paralysis agitans, 912 

(See also various other affections of 
the cord and brain) 

Rigors, 115 

(See also Ague, and other febrile and in- 
flammatory disorders) 
Rilliet and Barthez, on rickets, 806 
Rindfleisch on carcinoma, 91 

on epithelioma, 94 

on lardaceous liver, 703 

on mollities ossium, 808 

on proud flesh, 68 

on tubercle, 83 
Ringworm (see Tinea Tonsurans), 321 
Risus sardonicus in spinal meningitis, 873 

in tetanus, 978 
Roberts, W., on alkalinity of uriue, 718 

on chyluria, 763 

on contagion, 141 

on diabetes insipidus, 772 

on suppression of urine, 773 

on uric acid calculi, 759 
Roe, fi., on treatment of hooping-cough, 
152 

Roger, on chorea, 944 

on rickets, 806 
Rokitansky on malignant jaundice, 712 
Roseola (see Erythema), 284 

epidemic (see Epidemic Roseola), 158 
Rotheln (^Epidemic Roseola), 158 
Round worms, 631 

common, description of, 632 
symptoms of, 632 
treatment of, 632 
Rubeola (see Epidemic Roseola and Measles) , 

154, 158 
Rupia, 302 

causation and description of, 302 
escharotica, 302 
prominens, 302 
treatment of, 302 
Rupture of heart (see Heart, rupture of). 
475 



ST. VITUS'S DANCE (see Chorea), 943 
Salicylates in enteric fever, 220 
in rheumatism, 788 
Salisbury, on palmellse as cause of ague, 243 
Salivary glands, affection of, in mumps, 152 
Salter, Hyde, on asthma, 428 et seq. 
Sanderson, Burdon, on cholera (experimen- 
tal production of), 225 
on contagium, 141 
on feorile process, 114 
on localization of functions of brain, 823 
on lymphatic tissue, 80 
on lymphatic tissue and tubercle, 83, 
84 

on pulse trace, 438 
on septicEemia, 142 

on tubercle (experimental production 
of), 87 

Sanguineous apoplexy, 926 

68 



Sanies, 65 

Sarcina ventriculi, 623, 639, 664 

in urine, 732 
Sarcoma (see also Morbid Growths), 88 

of abdominal lymphatics, 621 

of bowels, 621 

of brain and cord, 919 

cysto-, 89 

glio-, 89 

of kidney, 753 

large-cell, 90 

lipomatous, 89 

of liver, 695 

of mediastinum, 702 

melanoid, 90 

myxo-, 89 

osteo-, 89 

round-cell, 89 

of peritoneum, 702 

spindle-cell, 89 

of stomach, 702 
Scab, meaning of term, 277 
Scabies, 317 

acarus in, 317 

burrows or cuniculi in, 318 

causation and description of, 317 

Norvegica, 318 

treatment of, 319 
Scarlatina (see Scarlet Fever), 160 
Scarlet fever, 160 

albuminuria in, 163 

anginose, 164 

causation of, 160 

complications and sequelse of, 163 

definition of, 160 

dropsy in, 165 

history of, 160 

incubation of, 161 

latent, 164 

malignant, 164 

morbid anatomy of, 166 

puerperal fever, relation of, with, 164 

rheumatism in, 165 

simple, 164 

symptoms and progress of, 161 
treatment of, 166 
Schiff, on cause of diabetes, 770 
Schmidt's saline solution for injection in 

cholera, 233 
Schunck on coloring matter in urine, 724 
Sciatica, 784, 1007 
Scirrhus, 92 

of bowel, stomach, and peritoneum, 619 
Scleriasis (see Scleroderma), 311 
Scleroderma, 311 

causation and description of, 311 
treatment of, 312 
varieties of, 311 
Scleroma (see Scleroderma), 311 
Sclerosis (of nerve-centres), 882 
disseminated, 905 

apoplectiform attacks in, 909 
causation of, 905 
contraction of limbs in, 908 
definition of, 905 
expression in, 909 
eye-affection in, 907 
mental condition in, 909 
morbid anatomy of, 905 
paresis in, 908 



1074 



INDEX. 



Sclerosis, disseminated, rhythmical tremors 
in, 906 

speech, affection of, in, 908 
stages of, 909 

symptoms and progress of, 906 
treatment of, 910 
vertigo in, 908 
lateral, 892 

causation of, 892 
definition of, 892 
morbid anatomy of 893 
symptoms and progress of, 894 
treatment of, 896 
pathology of, 882 
Sclerostoma duodenale, 634 
Scolex of tapeworms, 625 et seq. 
Scorbutus (see Scurvy), 543 
Scrivener's palsy (see Writer's Cramp), 1001 
Scrofula (see Tubercle of Lymphatics), 525 
Scurvy, 537 

causation of, 537 
definition of, 537 
morbid anatomy of, 539 
symptoms and progress of, 538 
treatment of, 539 
Seat-worm (see Thread-worm), 633 
Sebaceous tumors (see Acne), 303 
Seborrhcea, 303 

causation and description of, 303 
treatment of, 305 
Sedgwick, W., on variations of urine in in- 
testinal obstruction, 652 
Seidel on galvanism in diabetes insipidus, 
772 

Senator on urine in tetanus, 979 
Septicaemia, 142 

(See also Pyaemia, 250) 
Serous membranes, affection of, in pyaemia, 
250 

Sex, as cause of disease, 38 

Shaking palsy (see Paralysis Agitans), 910 

Sheep-pox, contagium of, 141 

Shingles (see Herpes), 298 

Sibson, on reduplication of heart's sounds 

in renal disease, 734 
Sick-headache (see Megrim), 955 
Sight, affection of, in megrim, 956 
Simon, J., on cancerous dyscrasia, 56 

on cysts of kidney, 748 
Skin, diseases of, 274 et seq. 

in syphilis, 242, 246 
Skoda on bronchophony, 350 

on consonance, 348 

on tubular sounds, 348 
Smallpox, 167 

causation of, 167 

complications of, 170 

confluent, 170, 172 

definition of, 167 

discrete, 170, 172 

history of, 167 

incubation of, 168 

inoculation of, 175 
on cattle, 175 

malignant, 173 

modified (varioloid), 173 

morbid anatomy of, 173 

mortality of, 173 

in pregnancy, 173 

secondary fever in, 169 | 



Smallpox, symptoms and progress of, 168 

treatment of, 174 
Smith, E , on mortality of hooping-cough, 
151 

Smith, Dr. J. Lewis, on cholera infantum, 
673 

Snow, on cause of cholera, 224 
Softening of brain (see Obstruction of Cere- 
bral Arteries), 936 
Solitary glands, affection of in cholera, 230 

of in enteric fever, 217 
Southey on treatment of anasarca, 751 
Spasm, 840 

of bronchial tubes (see Asthma), 428 
of larynx and trachea, 427 

treatment of, 427 
of oesophagus, 575 
Spasmodic wry-neck (see Wry-neck), 1001 
1002 

Spasms, local functional, 1001 

tonic, in tetanus, 977 
Specialized tissues, 48 
Specific causes of fevers, 137 

fevers, 137 et seq. 
Speech, defect of in chorea, 946 

in disseminated sclerosis, 907 
in glosso-labio-laryngeal palsy, 902 
903 

in tabes dorsalis,.900 
loss of power of, 851 

pathology of, 851 
Sphygmograph, 438 
Spina bifida, (see Hydrorrhachis), 940 
Spinal cord, affection of, in syphilis, 245 
anaesthesia, 839 

dropsy (see Hydrorrhachis), 939 
epilepsy in disseminated sclerosis, 908 
hemorrhage, 926, 929 

causation of, 926 

morbid anatomy of, 926 

symptoms and progress of, 933 

treatment of, 934 
irritation, 972 
nerves, paralysis of, 999 

causation of, 999 

symptoms and diagnosis of, 999 

treatment of, 1000 
paralysis (see Paraplegia) , 833 

adult (see Paralysis, Spinal Adult;, 
889 

general (see Paralysis, Spinal Gene- 
ral), 887 

infantile (see Paralysis, Spinal Infan- 
tile), 884 
Spine, affection of, in hysteria, 972 
Spirilla in blood in relapsing fever, 142 
Spirometer, 339 
Splashing sound, 353 
Spleen, in ague, 268, 270 
atrophy of, 523 
congestion of, 519 
causation of, 519 
morbid anatomy of, 519 
symptoms and progress of, 520 
treatment of, 520 
cysts of, 523 
diseases of, 519 et seq. 
hydatids of, 523 
hypertrophy of, 520 
causation of, 520 



INDEX. 



1075 



Spleen, hypertrophy of, in enteric fever, 219 
morbid anatomy of, 520 
in relapsing fever, 192 
symptoms and progress of, 520 
treatment of, 521 
inflammation of, 521 
causation of, 521 
morbid anatomy of, 521 
symptoms of, 522 
treatment of, 522 
lardaceous degeneration of, 523 
morbid anatomy of, 523 
symptoms of, 524 
treatment of, 524 
tubercle of, 522 , 
tumors of, 522 
symptoms of, 523 
Splenic fever, bacilli in blood in, 141, 142 
Spread of epidemic and endemic diseases, 
137 

Sputa (see Expectoration), 334 
Squamae, meaning of term, 277 
Willan's second order, 277 
Squinting in oculo-motor paralysis (see also 
Meningitis, Tabes Dorsalis, and other 
nervous diseases), 993 
Squire, W., on latency of influenza, 147 

B., on pediculi, 316, 317 
Stadeler on bile and blood pigment, 99 
Startin, Jas., on treatment of lupus, 308 
Status epilepticus, 957 
Stethoscope, 344 
Stigma, meaning of term, 274 
Stokes on treatment of bronchitis, 367 
Stomach, cirrhosis of, 614 

morbid anatomy of, 614 
symptoms of, 614 
degenerative affections of, 638 
hemorrhage from (see Hemorrhage from 

Stomach and Bowels), 658 
inflammation of (see Gastritis), 581 
malignant disease of, 619 
colloid, 620 
encephaloid, 620 
lymphadenoma, 621 
sarcoma, 621 
scirrhus, 619 
symptoms of, 622 
treatment of, 625 
obstruction of, 638 
causation of, 638 
morbid anatomy of, 638 
symptoms and progress of, 639 
treatment of, 640 
ulceration of, 590 
causation of, 590 
hemorrhage in, 592 
morbid anatomy of, 590 
perforation in, 592 
symptoms and progress of, 590 
treatment of, 593 
Stomatitis gangrenosa (see Noma and Gan- 
grene of Fauces), 563 
ulcerative, 562 
causation of, 562 
morbid anatomy of, 562 
symptoms and progress of, 562 
treatment of, 562 
Stone, H. W., on aegophony, 351 
Stones (see Calculi). 



Strangulation, internal, of bowels, 645 
causation of, 645 
morbid anatomy of, 645 
symptoms of, 646 
treatment of, 653 
Stricture of bowels, 641 
causation of, 641 
morbid anatomy of, 641 
results of, 641 

symptoms and progress of, 643 
treatment of, 653 
of oesophagus, 571 et seq 
Stridulous laryngitis, 358, 360 
Strongy] us gigas, 755 
Strophulus (see Eczema), 293 

albidus, 303 
Struthers on olfactory nerves, 818 
Succussion, 353 
Sudamina, 297 
Sugar in urine, 725 
tests for, 725 

(See also Diabetes), 766 
Sunstroke, 981, 984 
causation of 984 
definition of, 984 
morbid anatomy of, 985 
pathology of, 985 
symptoms and progress of, 984 
treatment of, 985 
Suppression of urine (see Urine, Suppression 
of), 772 
in cholera, 227 
in enteritis, 652 
in hysteria, 971 
Suppuration, 65 

Supra-renal capsules, diseases of, 515 et 
seq. 

morbid growths of, 518 
tubercle of (see Addison's Disease), 
515 

Sutton on cholera stools, 228 
Sycosis (see Acne), 303 
(see Impetigo), 296 
(see Tinea Tonsurans), 323 
Sydenham on epidemic constitution, 41 

on treatment of chorea, 950 
Sympathetic system, influence of, over mor- 
bid processes, 843 
Syncope, 122, 123, 477 
causation of, 477 
symptoms of, 122 
treatment of, 477 
Syphilis, 238 

causation of, 238 
definition of, 238 
history of, 238 
incubation of, 240 
inherited, 245 

abortion in connection with, 246 
affection of teeth in, 246 
keratitis in, 247 
inoculation of, 239, 248 
morbid anatomy and pathology of, 247 
primary symptoms of, 240 

Hunterian chancre, 240 
lymphatic glands, affection of, 
241 

protection afforded by one attack, 240 
secondary symptoms of, 240 
corona veneris, 241 



1076 INDEX. 



Syphilis, secondary, eruptive stage, 241 
erythema circinatum, 241 
eye affection, 242 
raucous tubercles, 242 
nodes, 242 
psoriasis, 242 
pustules, 242 
roseola, 241 
tubercles, 242 
vesicles and blebs, 241 
sequelae of, 245 

symptoms and progress of, 240 
tertiary symptoms of, 242 
gummata, 242 
of locomotor organs, 244 
of mucous membranes, 244 
of skin, 242 
of viscera, 245 
transmission of, from parent to chil- 
dren, 239 
treatment of, 248 
Syphilitic disease of arteries, 486 

of brain and cord (see Morbid 
Growths of Brain and Cord), 
916, 917, 924 
of heart, 468 
of kidney, 753 

of liver (see Morbid Growths of 

Liver), 692 
of mouth, fauces, etc , 570 
of respiratory organs, 402 

morbid anatomy of, 402 

symptoms of, 403 

treatment of, 403 
of testes, 245 



TABES dorsalis, 896 
brittleness of the bone in, 898 
causation Of, 896 
definition of, 896 
morbid anatomy of, 896 
symptoms and progress of, 897 
treatment of, 902 
Tache cerebrale, 864, 871, 873 
Taenia echinococcus, description of, 629 
mediocanellata, description of, 628 
symptoms of, 628 
treatment of, 629 
solium, description of, 627 
symptoms of, 628 
treatment of, 629 
Taeniada, general account of, 626 
Tapeworms, general account of, 626 
Taylor, A. S., on lead-poisoning, 550, 553 

F., on hepatic pulsation, 447 
Teale on spinal irritation, 972 
Teeth, affection of, in congenital syphilis, 
246 

Temperature, abnormal, 113 
in collapse, 122 
death from high, 117 
degradation of tissues as cause of 

high, 117 
in hectic fever, 118 
symptoms of. referable to circulatory 
organs, 114 
digestive organs, 114 
nervous system, 115 
respiratory organs, 114 



Temperature, symptoms of, referable to 
skin, 114 
urinary organs, 115 
in typhoid condition, 121 
varieties of, 114 
normal, 112 
cause of, 112 
regulation of, 113 

(See also the different diseases) 
Ten don reflexes, 837 
Tertian ague, 267 

Testicle, affection of, in leprosy, 262 
mumps, 153 
syphilis, 245 
Tetanus, 977 

causation of, 977 
definition of, 977 
diagnosis of, 980 
emprosthotonos in, 979 
morbid anatomy of, 980 
opisthotonos in, 979 
pleurosthotonos in, 979 
prognosis of, 979 
risus sardonicus in, 978 
stiffness of muscles in, 978 
symptoms and progress of, 978 
temperature in, 979 
tonic spasms in, 978 
treatment of, 980 
trismus or lock-jaw in, 979 
Therapeutical treatment, 130 

administration of nourishment, 133 
attention to patient's comforts, 131 
cure of disease, 130 
elimination of poisonous matter, 133 
maintenance of strength, 132 
obviation of tendency to death, 134 
of secondary phenomena or symp- 
toms, 133 
Thermometer, use of, 118 
Thiersch, on experimental production of 

cholera, 225 
Thread-worm, common, description of, 633 
symptoms of, 633 
treatment of, 633 
Thrill, hydatid, 698 
Thrombosis, 500 

causation of, 500 

of cerebral arteries (see Cerebral Ar- 
teries, obstruction of), 934 
morbid anatomy of, 500 
in arteries, 502 
in heart, 500 
in veins, 501 
in pyaemia (see Pyaemia), 250 
symptoms of, 504 
cardiac, 505 
multiple, 506 
pulmonic, 505 
systemic arterial, 506 
systemic venous, 504 
treatment of, 505, 507 
of venous sinuses, 860 
Thrush, 560 

causation of, 560 
morbid anatomy of, 560 
oidium albicans in, 560 
symptoms and progress of, 561 
treatment of, 561 
Thudichum on blood in-cholera, 231 



INDEX. 



1077 



Thudichum on gall-stones, 704 
Thyroid body, carcinoma of, 508 
diseases of, 508 

hypertrophy of (see Goitre), 508 
(See also Graves's Disease), 477 

inflammation of, 508 
Tic douloureux, 1003, 1007 

symptoms of, 1007 

treatment of, 1007 
Tinea decalvans (see Alopecia Areata), 2! 
favosa, 323 

achorion Schoenleinii in, 323 

causation of, 323 

description of, 323 

treatment of, 324 
tonsurans, 321 

causation of, 321 

description of, 321 

treatment of, 323 

tricophyton tonsurans in, 321 
versicolor, 325 

causation of, 325 

description of, 325 

microsporon furfur in, 325 

treatment of, 325 
Tinkling, metallic, 349 
Tissues, connective, 47 
epithelial, 47 
physiological, 47 
specialized, 47 
Todd on alcohol in pneumonia., 375 

on hemiplegia in cerebral softening, 

936 

Tone of paralyzed muscles, 835 

Tongue, enlargement of, in children, 529 

inflammation of (see Glossitis), 565 
Tonic spasms, description of, 841 
Tonsil, inflammation of (see Quinsy), 566 

in scarlet fever, 161, 164 
Tonsillitis (see Quinsy), 566 
Tophi (see Gout), 795 
Torsion of bowel, 644 

causation of, 644 
morbid anatomy of, 644 
symptoms of, 644 
treatment of. 653 
Torticollis, rheumatic, 785 

spasmodic (see Wry-neck), 1001, 1002 
Torula cerevisise (yeast-plant) in urine, 732 

in vomit. 624, 639, 664 
Trachea, congestion of, 417 

diphtheritic affection of, 204 
inflammation of (see Laryngitis), 355 
spasm of, 428 

syphilitic disease of (see Syphilitic Dis- 
ease of Respiratory Organs), 402 
Tracheitis (see Laryngitis), 355 
Tracheotomy in diphtheria, 209 
Traction of bowel (see Compression of 

Bowel), 644 
Trapp's formula for determining solids in 

urine, 720 
Treatment of disease, 128 
hygienic, 128 
prophylactic, 129 
therapeutical, 130 

(See also the different diseases) 
prophylactic, of fevers, 144 
(See also different fevers) 
Tremor, purring, in. heart disease, 449, 454 



Tremors, 840 

in disseminated sclerosis, 906 

in mercurial poisoning, 555 

in paralysis agitans, 911 
Trendelenburg on inoculation of diphtheria, 
202 

Trichina spiralis, description of, 634 
Trichinosis, 634 

symptoms and progress of 635 

treatment of, 636 
Tricophyton tonsurans, 321 
Tricuspid valve disease, diagnosis of, 454 
effects of, on heart, 446 
prognosis of, 457 
treatment of, 457 
Trismus (see Tetanus), 979 

neonatorum, 977, 980 
Trommer's test for sugar, 725 
Trousseau on adenia, 530 

on anaemia, 530 

on aphasia, 856 

on belladonna in hooping-cough, 152 
on chorea, 945 
on constipation, 653 
on delirium in smallpox, 172 
on delirium tremens, 540 
on diabetes insipidus, 772 
on diarrhoea, 669 et seq. 
on diarrhoea in dyspepsia, 665 
on dysentery, 607 
on epidemic roseola, 158 
on epilepsy, 951 et seq. 
on epileptiform neuralgia, 1006 
on Graves's disease, 478 
on hemiplegia in cerebral softening, 936 
on hooping cough, 151 
on hydrocephalic cry, 871 
on hydrocephalus, 941 et seq 
on hydrochloric acid in diphtheria, 209 
on inoculation of diphtheria, 202 
on mollities ossium, 808, 809 
on multiple puncture of hydatid cysts, 
700 

on painful spots in neuralgia, 1004 

on paracentesis thoracis, 384 

on paralysis agitans, 913 

on recovery of arm before leg in hemi- 
plegia, 933 

on rheumatoid arthritis, 793 

on swelling of hands and feet in con- 
fluent smallpox, 172 

on tabes dorsalis, 900 

on tache cerebrale, 864, 873 
Tubercle, 83 

of abdominal lymphatic glands, 616 

of bowels (see Bowels, Tubercle of), 
615 

of brain and cord (see Morbid Growths 

of Brain and Cord), 916 
Charcot on, 85, 86 
crude or yellow, 84 
cutaneous, meaning of term, 275 
of digestive organs, 615 et seq. 
of Fallopian tubes, 777 
in glanders, 236 
gray or miliary, 83 
of heart and pericardium, 469 
inoculation of, 86 

of kidneys (see Kidney, Tubercle of), 
752 



1078 



INDEX. 



Tubercle, Klein on, 85 

of larynx (see Respiratory Organs, Tu- 
bercle of), 389 
of liver, 693 

of lungs (see Respiratory Organs, Tu- 
bercle of), 389 

of lympbatics (see Lympbatics, Tu- 
bercle of), 525 

microscopic description of, 83 

of meninges (see Meningitis), 868 

of mouth, fauces, etc., 570 

of ovaries, 760 

of peritoneum (see Peritoneum, Tuber- 
cle of), 615 
of pleura (see Respiratory Organs, Tu- 
bercle of), 389 
quasi-malignancy of, 86 
relation of adenoid tissue, 84 
relation between gray and crude, 85 
seat of, 83, 87 

of spleen (see Spleen, Tubercle of), 522 
of supra-renal capsules (see Addison's 

Disease) , 515 
of urinary bladder, 775 
of uterus, 777 
Tubercula, Willan's seventh order, 276 
Tubercular laryngitis (see Laryngitis), 356, 
358 

meningitis (see Meningitis), 868 
Tuberculosis (see Tubercle) 
Tubular breathiDg, 34-7 
Tumors, 72 

adenoid, 95 

angioma or vascular, 77 
carcinoma, 91 

chondroma or cartilaginous, 75 

classification of, 72 

colloid, 93 

complex, 72 

connective-tissue, 73 

encepbaloid, 92 

epithelioma, 94 

fibroma or fibrous, 75 

glioma or glue-like, 75 

granuloma, 82 

gummata, 87 

histoid, 72 

lipoma or fatty, 74 

lympbadenoma, 78 

lymphangioma, 78 

myoma or muscular, 77 

myxoma or mucous, 74 

neuroma or nervous, 77 

organoid, 72 

osteoma or osseous, 76 

sarcoma, 88 

scirrhus, 92 

scrofulous glands, 79 

teratoid, 72 

tubercle, 82 

(See also different organs) 
Twisting of bowel (see Torsion), 643 
Tympanites, 589 (and various abdominal 

affections) 
Tympanitic resonance, 342 
Type, change of, in disease, 41 
Typhlitis, 599 

causation of, 599 

morbid anatomy of, 599 

symptoms and progress of, 600 



Typhlitis, treatment of, 601 
| Typhoid condition, 119 
symptoms of, 119 
i Typhoid fever (see Enteric Fever), 210 
; Typho-malarial fever, 273 
Typhus, 182 

abdominal (see Enteric Fever), 210 

causation of, 182 

causes of death in, 186 

complications of, 186 

definition of, 182 

history of, 182 

incubation of, 183 

morbid anatomy of, 187 

mortality of, 186 

pregnancy and, 186 

symptoms and progress of, 183 

treatment of, 187 

varieties of, 186 
Tyrosine, 724 



ULCER, duDdenal, 598 
Ulceration, 67 
of bowels (see Bowels, Ulceration of), 

593 

(See also Enteric Fever, and Tu- 
bercle of Bowels) 
of bronchial tubes, 361, 389 
of caecum (see Typhlitis) , 599 
of colon (see Dysentery), 602 
of larynx, 355, 389 
of mouth, 561, 562 
of oesophagus, 571 
of rectum (see Periproctitis), 601 
of stomach (see Stomach, Ulceration 

of), 589 
of trachea, 355, 389 
Ulcerative endocarditis, 507 
Ursemia, 733 

in scarlet fever, 165 
in suppression of urine, 773 
in the typoid condition, 121 
Urates deposited in gout, 795 
in urine, 724 

forms of, 724 
tests for, 724 
Uratic calculi, 732 

degeneration, 100 
Urea, 721 

tests for, 722 
Uric acid, 723 

calculi, 732 
Urinary bladder, diseases of, 774 
dilatation of, 775 

symptoms of, 775 
treatment of, 776 
inflammation of, 774 
symptoms of, 775 
morbid growths of, 775 
tubercle of, 775 
concretions, 732, 757 
causation of, 757 
chemistry of, 732 

ammoniaco-magnesian phosphate, 
732 

amorphous phosphate, 733 
carbonate of lime, 733 
cystine, 733 
fusible, 733 



INDEX. 



1079 



Urinary concretions, chemistry of, indigo, 
733 

oxalate of lime, 733 
uratic, 733 
uric acid, 733 
xanthine, 733 
morbid anatomy of, 757 
symptoms and progress of, 758 
treatment of, 759 
organs, affection of, in hysteria, 970 
Urine, bloody (see Hasmaturia, and Pa- 
roxysmal Hematuria), 764, 765 
chyl us (see Chyluria), 762 
diseased, 721 

albumen, in, 727 

ammoniaco-magnesian phosphate 
in, 727 

amorphous phosphate of lime in, 
727 

bacteria in, 732 
bile in, 729 

bilharzia hsematobia in, 732 

blood in, 728 

carbonate of lime in, 727 

casts in, 729 

chyle in, 762 

coloring matter of blood in, 729 
coloring matters in, 725 
crystallized phosphate of lime in, 
725 

cystine in, 724 
echinococci in, 732 
fat in, 731 

filaria sanguinis hominis in, 732 

hydatids in, 732 

leucine in, 724 

morbid growths in, 732 

mucus in, 731 

odorous matters in, 725 

oxalate of lime in, 727 

penicilium in, 732 

physical characters of, 721 

pus in, 731 

quantity of, 721 

quantity of solids in, 720 

reaction of, 720 

salts in, 727 

sarcinae in, 732 

specific gravity of, 721 

spermatozoa in, 732 

sugar in, 725 

tyrosine in, 724 

urates in, 724 

urea in, 721 

uric acid in, 723 

xanthine in, 724 

yeast-plant in, 732 
healthy, 706 

constituents of (enumeration), 720 

determination of solids in, 720 

quantity of, 719 

specific gravity of, 719 
retention of constituents of, in blood, 
consequences of, 733 

anasarca, 733 

congestion, 734 

dropsy, 735 

hemorrhage, 735 

hypertrophy of heart, 734 

inflammation, 735 



Urine, retention of constituents of, conse- 
quences of, thickening of blood- 
vessels, 735 
uraemia, 736 
suppression of, 

in cholera, 227 
functional, 772 
in hysteria, 941 

from obstruction of ureters, 773 
causation of, 773 
morbid anatomy of, 773 
symptoms and progress of, 773 
treatment of, 774 
in obstruction of bowels, 652 
Urticaria (see Erythema), 284, 287 
evanida, 287 
factitious, 288 
febrilis, 287 
perstans, 288 
treatment of, 288 
Uterus, dilatation of, 778 
inflammation of, 776 
causation of, 776 
morbid anatomy of, 776 
symptoms of, 776 
malignant disease of, 777 
myomata of, 777 

symptoms of, 777 
tubercle of, 777 



VACCINATION, 175 
Badcock on, 176 
Ceely on, 176 
dangers of, 178 
history of, 178 
Jenner on, 178 
Mar son on, 178 
performance of, 179 
precautions as to, 179 
protectiveness of, against variola, 178 
repetition of, 179 
Vaccine-lymph, mode of taking, 180 
Vaccinia (see Cow-pox), 175 

experiments with regard to the conta- 
gium of, 142 
Valleix on painful spots in neuralgia, 1004 
Valves of heart, degenerative affections of, 
472 

causation of, 472 
morbid anatomy of, 472 
symptoms of, 472 
treatment of, 472 
rupture of, 476 
Valvular lesions (see the several valves) 
Varicella (see Chicken-pox), 180 
Variola (see Smallpox), 167 
Varioloid (see Smallpox), 167 
Varix, 499 

causation of, 499 
Varix, morbid anatomy of, 499 
Vascular organs, diseases of, 434 et seq 

tumors, 77 
Veins, dilatation of (see Varix), 499 
diseases of, 498 et seq. 
embolism of (see Embolism), 502 
obstruction of, 500 
thrombosis of (see Thrombosis), 500 
Venous murmur, 451 

sinuses, obstruction of, 863, 920 



1080 



INDEX. 



Ventricles of brain and cord, anatomy of, 
811 

dropsy of {see Hydrocephalus and 

Hydrorrhachis), 939 
effusion of blood into, 928, 932 
of heart, diseases of [see Heart, etc.; 
Verruca necrogenica, 307 
Vertebrae, caries of {see Dura Mater, In- 
flammation of), 861, 864 
Vertigo, 850 

aural {see Meniere's Disease), 989 
in disseminated sclerosis, 908 
epileptic, 954 

in morbid growths of brain, 921 

pathology of, 850 

varieties of, 850 
Vesicles, meaning of term, 276 
Vesiculae (Willan's sixth order), 276 
Vesicular emphysema (see Emphysema), 412 
Vibices, meaning of term, 275 
Villemin on inoculation of tubercle, 87 
Virchow on carcinoma, 91 

on catarrh of hepatic ducts, 712 

on cell-districts, 48 

on classification of tumors, 73 

on cloudy swelling, 96 

on cretinism, 512 

on elephantiasis, 313 

on elephantiasis Arabum, 78 

on enchondroma, 75 

on erysipelas, 281 

on fibrine in inflammation, 57 

on glioma, 75 

on goitre, 509 

on goitre (submaxillary), 510 
on granuloma, 83 
on hyperplasia,. 58 
on jaundice, 678 
on keloid, 309 

on lardaceous degeneration, 97 

on leprosy, 261, 262 

on leucocythemia, 82, 529 

on mollities ossium, 808 

on molluscum contagiosum, 315 

on physiological tissues, 47 

on psammoma, 90 

on pyaemia, 253 

on sarcoma, 88 

on scrofulous glands, 80 

on syphilitic disease of liver, 693 

on tongue-enlargement in children, 528 

on tubercle, 85 

on tubercle of oral mucous membrane, 
570 

on white hepatization of lungs, 403 
Vital causes of disease, 44 

properties of protoplasm, 49 
Vitiligoidea {see Xanthoma), 308 
Vocal fremitus, 338 
Vogel, Alfred, on urea in pyaemia, 116 
Voice, absence of, 330 

auscultation of, 346, 349 

in cholera, 226 

compass of, 331 

feebleness of, 331 

in leprosy, 260 

pathology of, 330 

pitch of, 331 

quality of, 331 
Volkmann, on infantile paralysis, 887 



Vomicae, detection of, 354 

{See also Pneumonia, Cirrhosis, Tuber- 
cular Di ease, and Morbid Growths 
of the Lungs) 
Vomit, black, in yellow fever, 196 
Vomiting of blood {see Hemorrhage from 
Stomach), 658 
in dyspepsia, 663 
in epidemic cholera, 226 
in hysteria, 970 
in megrim, 985 
in Meniere's disease, 990 
in morbid growths of brain, 920 
in obstruction of bowels, 651 
in obstruction of stomach, 640 
in tubercular meningitis, 871 

{See also various affections, especially 
of stomach and bowels) 
Von Barensprung on zona, 299 



WAGSTAFFE on collapse temperatures, 
123 

Warehouseman's itch {see Eczema), 290, 294 
Wasting palsy {see Muscular atrophy, pro- 
gressive), 889 
Water on the brain {see Hydrocephalus), 

939 

on the chest {see Hydrothorax, 418, and 
Hydropericardium, 476) 
Water-brash, 664 

Watson, Eben, on nitrate of silver in hoop- 
ing-cough, 153 
Watson, Spencer, on cystic goitre, 509 
Watson, Sir Thos., on ague, 264, 270 

on apoplexy, 934 

on catarrh, 559 

on chorea, 947, 951 

on hydrocephalus, 944 

on hysteria, 970, 974 

on lead-poisoning, 554 

on meningitis, 875 

on tetanus, 977 et seq. 
Waxy degeneration {see Lardaceous De- 
generation) 
Weber, H., on hyperpyrexia, 788 
Wells, Spencer, on ovarian tumors, 780 
Wens, 303 

Werlhofii, morbus maculosus {see Purpura), 
536 

West, C, on infantile convulsions, 963 

on infantile paralysis, 885 
Westphal on an early symptom of tabes 

dorsalis, 898 
Wheal, definition of, 276 
Whip-worm, description of, 634 
White hepatization of lungs, 403 
White cell blood {see Leucocythsemia 81, 

529 

Wilks on anaemia lymphatica, 529 
on delirium tremens, 548, 549 
on encephalitis, 879 
on verruca necrogenica, 307 

Willan on classification of skin-diseases, 274 
et seq. 

on erythema and roseola, 284, 286, 287 

on lepra and psoriasis, 289 v 

on prurigo, 327 

on strophulus albidus, 303 

on urticaria, 288 



INDEX. 



1081 



Wilson on classification of skin-diseases, 274 
Woodward, Dr. J. J., on typho-malarial 

fever, 273 
Worms, intestinal, 626 et seq. 
Wrist-drop {see Lead-poisoning), 550, 552 
Writer's cramp, 1001 

pathology of, 1002 

treatment of, 1003 
Wry-neck, spasmodic, 1001, 1002 

pathology of, 1003 

treatment of, 1003 
Wunderlich on temperature in enteric fever, 
215 



XANTHELASMA {see Xanthoma), 309 
Xanthine cnlculi, 733 
chemistry of, 724 
Xanthoma, 309 

causation of, 309 

connection with jaundice, 310, 680 
description of, 309 
planum, 309 
tuberosum, 309 
Xeroderma {see Ichthyosis), 291 



YELLOW ATROPHY of liver {see Jaun- 
dice, Malignant), 712 
Yellow fever, 195 

causation of, 195 

death, causes of, in, 196 

definition, 195 

diagnosis of, 196 

history of, 195 

incubation of, 195 

morbid anatomy of, 197 

mortality of, 196 

symptoms and progress of, 195 

treatment of, 197 



ZENKER on degeneration of muscle, 97 
on trichinosis, 634 
Ziemssen, von, on depressors of epiglottis, 
425 

Zona {see Herpes Zoster), 298 
Zoster {see Herpes Zoster), 298 
Zymotic diseases {see Specific Febrile Dis 
eases), 137 




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